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Clinical Practice Guidelines

AMELIA J.H. ARUNDALE, PT, PhD • MARIO BIZZINI, PT, PhD • AIRELLE GIORDANO, DPT • TIMOTHY E. HEWETT, PhD
DAVID S. LOGERSTEDT, PT, PhD • BERT MANDELBAUM, MD • DAVID A. SCALZITTI, PT, PhD
HOLLY SILVERS-GRANELLI, PT, PhD • LYNN SNYDER-MACKLER, PT, ScD, FAPTA

Exercise-Based Knee and


Anterior Cruciate Ligament
Injury Prevention
Clinical Practice Guidelines Linked to the International
Classification of Functioning, Disability and Health
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From the Academy of Orthopaedic Physical Therapy


and the American Academy of Sports Physical Therapy
J Orthop Sports Phys Ther. 2018;48(9):A1-A42. doi:10.2519/jospt.2018.0303

SUMMARY OF RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3
J Orthop Sports Phys Ther 2018.48:A1-A42.

METHODS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4
CLINICAL PRACTICE GUIDELINES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A7
AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS. . . . . . A22
REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A23
APPENDICES (ONLINE). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A26

REVIEWERS: Roy D. Altman, MD • Paul Beattie, PT, PhD • Marie Charpentier, DPT, ATC, LAT
John DeWitt, DPT, ATC • Amanda Ferland, DPT • Jennifer S. Howard, ATC, PhD
David Killoran, PhD • Leslie Torburn, DPT • James Zachazewski, DPT

For author, coordinator, contributor, and reviewer affiliations, see end of text. ©2018 Academy of Orthopaedic Physical Therapy, American Academy of Sports Physical
Therapy, and the Journal of Orthopaedic & Sports Physical Therapy. The Academy of Orthopaedic Physical Therapy, American Academy of Sports Physical Therapy, and
the Journal of Orthopaedic & Sports Physical Therapy consent to the reproduction and distribution of this guideline for educational purposes. Address correspondence
to Brenda Johnson, ICF-Based Clinical Practice Guidelines Coordinator, Academy of Orthopaedic Physical Therapy, APTA, Inc, 2920 East Avenue South, Suite 200, La
Crosse, WI 54601. E-mail: icf@orthopt.org
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

Summary of Recommendations*

REVIEW THE EVIDENCE IN THE SCIENTIFIC DESCRIBE THE EVIDENCE FOR COMPONENTS,
LITERATURE FOR EXERCISE-BASED KNEE DOSAGE, AND DELIVERY OF EXERCISE-BASED
INJURY PREVENTION PROGRAMS KNEE INJURY PREVENTION PROGRAMS
A Clinicians should recommend use of exercise-based knee A Exercise-based knee injury prevention programs used for
injury prevention programs in athletes for the prevention women should incorporate multiple components, proximal
of knee and anterior cruciate ligament (ACL) injuries. Programs control exercises, and a combination of strength and plyometric
for reducing all knee injuries include 11+ and FIFA 11, HarmoKnee, exercises.
and Knäkontroll; and those used by Emery and Meeuwisse,14
Goodall et al,20 Junge et al,34 LaBella et al,36 Malliou et al,41 Olsen A Exercise-based knee injury prevention programs should
et al,49 Pasanen et al,51 Petersen et al,52 and Wedderkopp et al.78 involve training multiple times per week, training sessions
Programs for reducing ACL injuries include HarmoKnee, Knäkon- that last longer than 20 minutes, and training volumes that are
troll, Prevent Injury and Enhance Performance (PEP), and Sports- longer than 30 minutes per week.
metrics; and those used by Caraffa et al,5 Heidt et al,27 LaBella et Clinicians, coaches, parents, and athletes should start
al,36 Myklebust et al,46 Olsen et al,49 and Petersen et al.52 A
exercise-based knee injury prevention programs in the
preseason and continue performing the program through the
IDENTIFY EXERCISE-BASED KNEE INJURY regular season.
PREVENTION PROGRAMS THAT ARE EFFECTIVE
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FOR SPECIFIC SUBGROUPS OF ATHLETES A Clinicians, coaches, parents, and athletes must ensure
high compliance with exercise-based knee injury
A Clinicians, coaches, parents, and athletes should imple-
prevention programs, particularly in female athletes.
ment exercise-based knee injury prevention programs
prior to athletic training sessions/practices or games in female Exercise-based knee injury prevention programs may not
B
athletes to reduce the risk of ACL injuries, especially in female need to incorporate balance exercises, and balance
athletes younger than 18 years of age. Programs that should be should not be the sole component of a program.
implemented include PEP, Sportsmetrics, Knäkontroll, Har-
moKnee, and those used by Olsen et al49 and Petersen et al.52
PROVIDE SUGGESTIONS FOR IMPLEMENTATION OF
Soccer players, especially women, should use exercise- EXERCISE-BASED KNEE INJURY PREVENTION PROGRAMS
J Orthop Sports Phys Ther 2018.48:A1-A42.

A
based knee injury prevention programs to reduce the risk of A Clinicians, coaches, parents, and athletes should imple-
severe knee and ACL injuries. Programs that could be beneficial for ment exercise-based knee injury prevention programs in
preventing severe knee injuries include PEP, Knäkontroll, and Har- all young athletes, not just those athletes identified through
moKnee. Programs that could be beneficial for specifically prevent- screening as being at high risk for ACL injury, to optimize the
ing ACL injuries include those used by Caraffa et al5 and numbers needed to treat while reducing cost.
Sportsmetrics.
A For the greatest reduction in future medical costs and
B Male and female team handball players, particularly those prevention of ACL injuries, osteoarthritis, and total knee
15 to 17 years of age, should implement exercise-based replacements, clinicians, coaches, parents, and athletes should
knee injury prevention programs. Programs that could be benefi- encourage implementation of exercise-based ACL injury preven-
cial for preventing knee injuries include those used by Olsen et tion programs in athletes 12 to 25 years of age and involved in
al49 and Achenbach et al.1 sports with a high risk of ACL injury.

B Clinicians, coaches, parents, and athletes should support


implementation of exercise-based knee injury prevention
programs led by either coaches or a group of coaches and medical
professionals.
*These recommendations and clinical practice guidelines are based on the scientific literature published prior to October 2017. Internet links to the individual programs
(when available) are provided in TABLE 4. In addition, the authors of this clinical practice guideline have created 2 videos (one for field sports and one for court sports,
available at https://www.jospt.org/doi/suppl/10.2519/jospt.2018.0303) that incorporate key elements of the various programs reviewed in this clinical practice guideline.

a2 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

List of Abbreviations
11+: an injury prevention program developed originally in FIFA 11: also known as “the 11,” an injury prevention
association with the medical committee of FIFA (previously program developed originally in association with the
known as FIFA 11+) medical committee of FIFA and the predecessor to the 11+
ACL: anterior cruciate ligament ICD: International Classification of Diseases
AE: athlete-exposure ICF: International Classification of Functioning,
AMSTAR: A Measurement Tool to Assess Systematic Disability and Health
Reviews JOSPT: Journal of Orthopaedic & Sports Physical Therapy
APTA: American Physical Therapy Association KLIP: Knee Ligament Injury Prevention program
CI: confidence interval PEDro: Physiotherapy Evidence Database
CPG: clinical practice guideline PEP: Prevent Injury and Enhance Performance injury
EMG: electromyography prevention program
FIFA: Fédération Internationale de Football Association RCT: randomized controlled trial
(international soccer governing body) SIGN: Scottish Intercollegiate Guidelines Network

Introduction
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AIM OF THE GUIDELINE • Provide suggestions for the implementation of exercise-


The Academy of Orthopaedic Physical Therapy and the based knee injury prevention programs.
American Academy of Sports Physical Therapy have an on- • Create a reference publication for athletes, coaches, parents,
going effort to create evidence-based clinical practice guide- students, interns, residents, fellows, athletic trainers, ortho-
lines (CPGs) for orthopaedic and sports physical therapy paedic and sports physical therapy clinicians, academic in-
management and prevention of musculoskeletal impair- structors, clinical instructors, and physicians and surgeons
ments described in the World Health Organization’s Interna- in orthopaedics and sports regarding the best current prac-
tional Classification of Functioning, Disability and Health tice of exercise-based knee injury prevention programs.
J Orthop Sports Phys Ther 2018.48:A1-A42.

(ICF).79 This particular guideline focuses on the exercise-


based prevention of knee injuries. Exercise-based prevention STATEMENT OF INTENT
was defined as an intervention requiring the participant(s) These guidelines are not intended to be construed or to
to be active and move. This could include physical activity; serve as a standard of medical care. Standards of care are
strengthening; stretching; neuromuscular, proprioceptive, determined on the basis of all clinical data available for an
agility, or plyometric exercises; and other training modali- individual athlete/patient and are subject to change as scien-
ties, but excludes passive interventions such as bracing or tific knowledge and technology advance and patterns of care
programs that only involve education. Knee injuries were evolve. These parameters of practice should be considered
defined as any knee joint pathology including damage to guidelines only. Adherence to them will not ensure a suc-
the joint (patellofemoral and/or tibiofemoral), ligaments, cessful outcome in every athlete or patient, nor should they
meniscus, or patellar tendon. The recommendations can be be construed as including all proper methods of care or ex-
followed and implemented by athletes, coaches, health and cluding other acceptable methods of care aimed at the same
fitness professionals, athletic trainers, physical therapists, results. The ultimate judgment regarding a particular injury
physicians, surgeons, and other clinicians. prevention plan, clinical procedure, or treatment plan must
be made based on experience and expertise in light of the
The objectives of this CPG are as follows. presentation of the athlete or patient, the available evidence,
• Review the evidence in the scientific literature for exercise- available diagnostic and treatment options, and the athlete
based knee injury prevention programs. or patient’s values, expectations, and preferences. However,
• Identify exercise-based knee injury prevention programs when providing care for athletes/patients, we suggest that
that are effective for specific subgroups of athletes. significant departures from accepted guidelines should be
• Describe the evidence for the components, dosage, and de- documented in the athlete/patient’s medical records at the
livery of exercise-based knee injury prevention programs. time the relevant clinical decision is made.

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a3
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

Methods

The Academy of Orthopaedic Physical Therapy and the eates between evidence related to ACL injuries and all knee
American Academy of Sports Physical Therapy appointed injuries.
content experts with relevant physical therapy, medical, • Mechanism of injury included both contact (injuries as a
and surgical expertise as developers and authors of the result of collision with another person or object) and non-
CPG for exercise-based knee injury prevention. These contact (injuries that do not involve another individual or
experts were given the task of describing the interven- object).17 This CPG discusses contact and noncontact inju-
tions and evidence for exercise-based knee injury preven- ries together, unless specifically noted in the text.
tion. The authors declared relationships and developed a • Meta-analyses
conflict management plan, which included submitting a • Systematic reviews
Conflict of Interest form to the Academy of Orthopaedic • Randomized controlled trials (RCTs)
Physical Therapy, APTA, Inc. Funding was provided by the • Cost-effectiveness studies
Academy of Orthopaedic Physical Therapy and American • High-level cohort studies (critical appraisal score on the
Academy of Sports Physical Therapy, and by the APTA to Scottish Intercollegiate Guidelines Network [SIGN] check-
the CPG development team for travel and expenses for list of 5 or greater)
CPG development training. The CPG development team • Published in a peer-reviewed journal
maintained editorial independence. • Able to access full-text article
• Published and accessible in English
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With the assistance of a research librarian (T.H.), the authors


systematically searched PubMed, Scopus, SPORTDiscus, CI- EXCLUSION CRITERIA
NAHL, and the Cochrane databases for relevant articles. Lit- • Injury prevention programs aimed at preventing all lower
erature searches were performed in March 2015 and updated extremity injuries
in April 2016 and October 2017. Reference lists of included • Injury prevention programs aimed at preventing lower ex-
sources were hand searched for additional articles not identi- tremity injuries other than knee injuries (eg, ankle injury
fied in the searches (see APPENDIX A for full search strategies prevention programs)
and APPENDIX B for search dates and results, available at www. • Injury prevention programs aimed at modifying risk fac-
orthopt.org). tors for knee injuries (eg, modifying peak knee abduction
moment)
J Orthop Sports Phys Ther 2018.48:A1-A42.

Inclusion and exclusion criteria used to select relevant ar- • Non–exercise-based interventions (eg, prophylactic
ticles were as follows. bracing)
• Case series
INCLUSION CRITERIA • Case-control studies
• Exercise-based knee injury prevention • Case studies
- Studies needed to expressly state that knee injuries of any
kind were the specific target of the program and outcome This guideline focuses on exercise-based knee injury pre-
measure of the study. vention programs, and excludes broader programs aimed at
- Exercise-based prevention was defined as an intervention preventing lower extremity injuries. Lower extremity injury
requiring the participant to be active and move his or her prevention programs target a wide range of pathologies,
body. This could include physical activity; strengthen- thus selecting different exercises or focusing athlete feed-
ing; stretching; neuromuscular, proprioceptive, agility, back on joints other than the knee. Further, mechanisms of
or plyometric exercises; and other training modalities, prevention may also differ. Programs targeting risk factors
but excluded passive interventions such as bracing or for knee injuries (eg, programs focused on modifying knee
programs that only involved education. biomechanics during jump landing) were also excluded from
- Knee injuries were defined as any knee joint pathology this CPG. There are a number of modifiable and nonmodifi-
including damage to the joint (patellofemoral and/or tib- able risk factors for knee injuries. However, the magnitude
iofemoral), ligaments, meniscus, or patellar tendon. of each risk factor for an athlete can be dependent on many
• Articles that focused on preventing knee injuries as a other variables. For example, hormonal changes as a result
whole were included, but so too were articles focused on of menstruation may affect women but not men.21 Similarly,
only one type of knee injury (eg, anterior cruciate ligament asymmetries in jump landing have been associated with knee
[ACL] injuries or patellofemoral pain). This CPG delin- injuries in women31 but not, to date, in men. As an inter-

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Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

Methods (continued)

national group of experts in prevention, familiar with the (see APPENDIX E for quality-assessment scores, available at
prevention literature as a whole as well as that specific to www.orthopt.org). Recommendations were written based
knee injuries, the authors felt that these were appropriate on the included articles and were agreed on by all authors.
restrictions. APPENDICES A through J are available on the CPG web page
at www.orthopt.org.
Components of training programs were defined as different
exercise approaches involved in the prevention programs. This guideline was issued in 2018 based on the published lit-
For example, a program that only involved balance exercises erature up to October 2017. This guideline will be considered
was considered to only have 1 component, whereas a program for review in 2022, or sooner if significant new evidence be-
that involved strengthening and plyometric exercises was comes available. Any updates to the guideline in the interim
considered to have multiple components. Common compo- period will be noted on the Academy of Orthopaedic Physical
nents include flexibility, strengthening, plyometrics, balance, Therapy website (www.orthopt.org).
and agility.
LEVELS OF EVIDENCE
One author (D.S.) screened articles for full-text availabil- Articles were graded according to criteria adapted from the
ity and for publication in English and in peer-reviewed Centre for Evidence-based Medicine, Oxford, United King-
journals. Two authors (A.A. and A.G. or D.L.) then inde- dom for diagnostic, prospective, and therapeutic studies.56
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pendently screened articles for inclusion based on title In 4 teams of 2, authors came to consensus to assign a level
and abstract. The authors then discussed their findings. of evidence based on the quality assessment of each article
Any article that clearly did not meet inclusion criteria (see APPENDICES F and G for the evidence table and details on
based on title and abstract was excluded at this point, and procedures used for assigning levels of evidence, available
the full text of any article that the authors were unsure at www.orthopt.org). An abbreviated version of the grading
of or that seemed to clearly meet inclusion criteria was system is provided below.
then reviewed. Full-text reviews were performed indepen-
dently by the same authors. The authors met to review Evidence obtained from systematic reviews, high-quality diagnos-
I
their findings, and all disagreements on inclusion/exclu- tic studies, prospective studies, or randomized controlled trials
sion were resolved by discussion. Consensus was reached Evidence obtained from systematic reviews, lesser-quality diag-
J Orthop Sports Phys Ther 2018.48:A1-A42.

on all articles (see APPENDIX C for the flow chart of articles nostic studies, prospective studies, or randomized controlled
II
and APPENDIX D for the citations of articles included in this trials (eg, weaker diagnostic criteria and reference standards,
guideline, available at www.orthopt.org). improper randomization, no blinding, less than 80% follow-up)
III Case-control studies or retrospective studies
All authors were involved in the quality-assessment and da- IV Case series
ta-extraction process. Two authors independently assessed V Expert opinion
the quality of each article. The A Measurement Tool to As-
sess Systematic Reviews (AMSTAR) tool was used to assess GRADES OF EVIDENCE
the quality of meta-analyses and systematic reviews.58 The In teams of 2, the authors developed recommendations
Physiotherapy Evidence Database (PEDro) scale was used based on the strength of evidence, including how directly
to assess the quality of RCTs,75 the SIGN checklist was used the studies addressed exercise-based knee injury prevention
to assess the quality of cohort studies,59 and the Drummond programs. The strength of the evidence supporting each
checklist was used to assess the quality of cost-effectiveness recommendation was graded according to the previously
analyses.12 Authors established reliability in the use of each established methods and is provided on the next page. In
quality-appraisal tool by independently assessing articles developing their recommendations, the authors considered
not included in the CPG, discussing their scoring, and com- the strengths and limitations of the body of evidence and the
ing to consensus on areas of disagreement. Discrepancies in health benefits and risks of interventions.
quality ratings were resolved through discussion between
the 2 authors. Studies that were authored by a reviewer DESCRIPTION OF GUIDELINE REVIEW PROCESS AND VALIDATION
were assigned to an alternate reviewer. Studies with a quali- Identified reviewers who are experts in knee injury preven-
ty score less than 5 on any scale were considered low quality tion reviewed the CPG draft for integrity, accuracy, and to
and were not used in the development of these guidelines39 ensure that it fully represented the current evidence for the

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a5
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

Methods (continued)

GRADES OF RECOMMENDATION STRENGTH OF EVIDENCE holders, and experts in physical therapy practice guideline
Strong evidence A preponderance of level I and/or level II methodology.
A studies support the recommendation. This
must include at least 1 level I study DISSEMINATION AND IMPLEMENTATION TOOLS
Moderate A single high-quality randomized controlled In addition to publishing this guideline in the Journal of
B evidence trial or a preponderance of level II studies Orthopaedic & Sports Physical Therapy (JOSPT), it will be
support the recommendation
highlighted and posted on the CPG web page of the JOSPT
Weak evidence A single level II study or a preponderance of
and the Academy of Orthopaedic Physical Therapy (APTA)
level III and IV studies, including statements
C websites. These web pages have unrestricted public access.
of consensus by content experts, support the
recommendation Implementation tools and associated implementation strat-
Conflicting Higher-quality studies conducted on egies that will be made available for athletes, coaches, pa-
evidence this topic disagree with respect to their tients, physicians, surgeons, clinicians, educators, payers,
D
conclusions. The recommendation is policy makers, and researchers are listed in TABLE 1.
based on these conflicting studies
Theoretical/ A preponderance of evidence from animal CLASSIFICATION
foundational or cadaver studies, from conceptual models/ The primary International Classification of Diseases-10th Re-
E
evidence principles, or from basic science/bench vision (ICD-10) codes and conditions associated with exercise-
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research supports the recommendation


based knee injury prevention are: S83.2 Tear of the (medial)
Expert opinion Best practice based on the clinical experi-
F (lateral) meniscus of the knee, S83.4 Sprain and strain in-
ence of the guidelines development team
volving (fibular) (tibial) collateral ligament of knee, S83.5
Sprain and strain involving (anterior) (posterior) cruciate
condition. The guideline draft was also posted for public ligament of knee, S83.7 Injury to multiple structures of
comment and review on www.orthopt.org, and a notifica- knee, S83.6 Sprain and strain of other unspecified parts
tion of this posting was sent to the members of the Academy of the knee, and M22.2 Patellofemoral disorders.
of Orthopaedic Physical Therapy, APTA, Inc. In addition,
a panel of consumer/patient representatives and external The primary ICF activities and participation codes associated
stakeholders, such as claims reviewers, medical coding with exercise-based knee injury prevention are: d410 Chang-
J Orthop Sports Phys Ther 2018.48:A1-A42.

experts, academic educators, clinical educators, physician ing basic body positions, d450 Walking, d4552 Running,
specialists, and researchers, also reviewed the guideline. d4553 Jumping, d4559 Moving around, specified as di-
All comments, suggestions, and feedback from the expert rection changes while walking or running, d9200 Play,
reviewers, public, and consumer/patient representatives d9201 Sports, and d9202 Arts and culture.
were provided to the authors and editors for consideration
and revisions. Guideline development methods, policies, ORGANIZATION OF THE GUIDELINES
and implementation processes are reviewed at least yearly Topics are arranged in relation to the CPG objectives. For each
by the Academy of Orthopaedic Physical Therapy (APTA)’s objective, the summaries of the evidence, levels of evidence,
ICF-Based Clinical Practice Guideline Advisory Panel, in- recommendation(s), and grade(s) of recommendation(s) are
cluding consumer/patient representatives, external stake- provided.

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Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

Clinical Practice Guidelines


A summary of the content of the training programs and studies studies (n = 27 000) and found a pooled rate ratio of 0.46 (95%
on exercise-based knee injury prevention programs that met CI: 0.36, 0.60). Sadoghi et al57 examined 8 studies (n = 10 839)
the inclusion criteria for this CPG is found in TABLES 2, 3, and 4. and found a pooled risk ratio of 0.38 (95% CI: 0.20, 0.72).
Donnell-Fink et al9 examined 14 studies (n = 17 735) and found
a rate ratio of 0.49 (95% CI: 0.29, 0.85). The authors of this
OBJECTIVE study narrowed their analysis to examine noncontact injuries,
Review the evidence in the scientific literature for exercise- and found a rate ratio of 0.51 (95% CI: 0.30, 0.88). Programs
based knee injury prevention programs. Evidence includes in the meta-analysis showing efficacy in reducing ACL injuries
systematic reviews and meta-analyses that look at preven- include Caraffa et al,5 HarmoKnee,35 Heidt et al,27 Knäkon-
tion programs across populations (APPENDIX H, available at troll,77 LaBella et al,36 Myklebust et al,46 and Olsen et al,49 Pre-
www.orthopt.org, and TABLE 3). vent Injury and Enhance Performance (PEP),19 Petersen et al,52
and Sportsmetrics.29
Evidence
Three meta-analyses have examined exercise-based Evidence Synthesis
I knee injury prevention programs across popula- There is strong evidence for the benefits of exercise-based
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tions.9,18,57 One meta-analysis examined the efficacy knee injury prevention programs, including reduction in risk
in reducing all knee injuries as well as reducing ACL injuries for all knee injuries and for ACL injuries specifically, with
specifically,9 and 2 focused only on ACL injuries.18,57 All of the little risk of adverse events and minimal cost.
studies included in these meta-analyses involved athletes
(sporting or tactical/military), with participants being men Recommendation
and women of different ages and races, as well as with differ- Clinicians should recommend use of exercise-based
ent sports and skill levels. A knee injury prevention programs in athletes for the
prevention of knee and ACL injuries. Programs for
The exercise-based prevention programs included in these reducing all knee injuries include 11+ and FIFA 11, Har-
analyses employed a number of different intervention strat- moKnee, and Knäkontroll; and those used by Emery and
J Orthop Sports Phys Ther 2018.48:A1-A42.

egies, from neuromuscular and proprioceptive training to Meeuwisse,14 Goodall et al,20 Junge et al,34 LaBella et al,36
strengthening, stretching, and plyometric exercises. Many of Malliou et al,41 Olsen et al,49 Pasanen et al,51 Petersen et al,52
these programs employed more than one of these strategies, and Wedderkopp et al.78 Programs for reducing ACL injuries
and gave participants feedback on their form during exer- include HarmoKnee, Knäkontroll, Prevent Injury and
cises, particularly jump landings.9,18,57 Enhance Performance (PEP), and Sportsmetrics; and those
used by Caraffa et al,5 Heidt et al,27 LaBella et al,36 Myklebust
The pooled incidence rate ratio, based on 19 studies (n = et al,46 Olsen et al,49 and Petersen et al.52
19 143), indicated that exercise-based prevention programs
are effective in reducing the incidence of knee injuries (inci-
dence rate ratio = 0.73; 95% confidence interval [CI]: 0.61, OBJECTIVE
0.87).9 Programs in the meta-analysis showing efficacy in Identify exercise-based knee injury prevention programs that
reducing knee injuries include FIFA (Fédération Internatio- are effective for specific subgroups of athletes. Evidence in-
nale de Football Association) 11+25,61 and FIFA 11 ("The 11"),73 cludes systematic reviews, meta-analyses, and cohort stud-
HarmoKnee,35 and Knäkontroll77; and those used by Emery ies that specifically delineate populations (APPENDICES I and J,
and Meeuwisse,14 Goodall et al,20 Junge et al,34 LaBella et al,36 available at www.orthopt.org).
Malliou et al,41 Olsen et al,49 Pasanen et al,51 Petersen et al,52
and Wedderkopp et al.78 Evidence
Men
Pooled rate and risk ratios from the 3 meta-analyses9,18,57 ex- One systematic review examined the effects of exer-
amining the impact of exercise-based knee injury prevention
programs on incidence of primary ACL injuries indicate that
II cise-based prevention programs on ACL injuries in
only men.2 The review by Alentorn-Geli et al2 found
these programs are effective.18,57 Gagnier et al18 examined 14 that studies of exercise-based knee prevention programs in

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a7
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

men were primarily performed on soccer teams. The review greater reduction in ACL injuries (odds ratio = 0.27-0.28)
identified 1 program successful in reducing ACL injury rates. compared to women over 18 years of age (odds ratio = 0.78-
The Caraffa et al5 program reported ACL injury rates in the 0.84).45,80 Analyzing age based on tertiles, Myer et al45 found
intervention group of 0.15 ACL injuries per team per year and a statistically significant reduction in ACL injuries for the
in the control group of 1.15 ACL injuries per team per year. The youngest group, but not for the older 2 groups: ages 14 to 18
review also identified a study by Grooms et al25 that examined years (odds ratio = 0.28; 95% CI: 0.18, 0.42), ages 18 to 20
the 11+ program. Using a 1-season historical control, Grooms years (odds ratio = 0.48; 95% CI: 0.21, 1.07), and ages older
et al25 did not observe an ACL injury in either the control or than 20 years (odds ratio = 1.01; 95% CI: 0.62, 1.64).45 An
intervention season. additional study analyzed age in quartiles. Sugimoto et al68
found that female athletes 14 to 18 years of age had greater
Women reduction in ACL injury incidence (odds ratio = 0.29; 95%
Three meta-analyses indicate that, in women, exer- CI: 0.19, 0.44; P = .01) compared to those younger than 14
I cise-based injury prevention programs are effective
in reducing the risk of all ACL injuries, with pooled
years of age (odds ratio = 0.29; 95% CI: 0.01, 7.09; P = .45),
18 to 20 years of age (odds ratio = 0.48; 95% CI: 0.21, 1.07;
odds ratios ranging from 0.40 to 0.64.45,72,80 More specifically, P = .07), and older than 20 years of age (odds ratio = 1.01;
when reporting only noncontact ACL injuries, the pooled 95% CI: 0.62, 1.64; P = .97).
odds ratio was 0.38.72,80
Soccer
Programs identified by meta-analyses45,72,80 as being effec- A meta-analysis of RCTs found a protective effect
tive in reducing the risk for ACL injuries in women were the
PEP, Sportsmetrics, Knäkontroll, and HarmoKnee, as well
I of exercise-based knee injury prevention programs
in soccer players (men and women) for knee inju-
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as the programs used in the studies by Myklebust et al46 and ries (relative risk = 0.74; 95% CI: 0.55, 0.98). The study
Petersen et al.52 Common themes of these successful pro- found a reduction in ACL injuries, though this decrease in
grams were use of multiple types of exercises, participation incidence was not statistically significant (relative risk =
during the preseason or preseason and in-season, perfor- 0.66; 95% CI: 0.33, 1.32).22 Three prevention programs,
mance prior to training sessions/practices or games, and an however, were successful in significantly decreasing the inci-
emphasis on what is thought to be optimal lower extremity dence of ACL injuries in soccer players when compared to a
alignment.19,27,29,35,36,42,46,49,52,63,77 control group (PEP,42 Knäkontroll,77 and the program used
by Caraffa et al5).
Two programs were identified as being ineffective at prevent-
ing ACL injuries.72,80 The Knee Ligament Injury Prevention Three individual studies included in this CPG (using the PEP,
J Orthop Sports Phys Ther 2018.48:A1-A42.

(KLIP) exercise-based knee injury prevention program, used Knäkontroll, and HarmoKnee programs) examined the in-
by Pfeiffer et al54 with high school–aged adolescent girls and cidence of knee injuries.29,35,77 While all 3 studies showed a
women, was used after practices and games. Despite an odds decrease in the incidence of knee injuries,29,35,77 the reduc-
ratio of 2.05, suggesting a greater risk of incurring a noncon- tion was only statistically significant with the Knäkontroll
tact ACL injury for the athletes in their intervention group, program.77 All 7 individual studies included in this CPG
the wide 95% CI (0.21, 21.7) indicates a lack of statistical that examined ACL injury incidence in soccer players (PEP,
significance. Söderman et al60 found that a greater percentage Knäkontroll, KLIP, the program by Caraffa et al,5 Sportsmet-
of athletes in their intervention group incurred noncontact rics) found a decrease in ACL injuries.19,29,35,42,54,77
ACL injuries (intervention, 6.5%; control, 1.3%; no P value
reported) or other knee injuries, including those to the com- In female soccer players (n = 4564) between the
bined ACL and medial collateral ligament, medial collateral
ligament, lateral collateral ligament, posterior cruciate liga-
II ages of 12 and 17 years, the Knäkontroll program
reduced ACL injuries in the intervention group by
ment, and contusions (intervention, 12.9%; control, 7.7%; no 64% (rate ratio = 0.36; 95% CI: 0.15, 0.85) and severe knee
P value reported), than those in their control group. Unlike injuries by 30% (rate ratio = 0.70; 95% CI: 0.42, 1.18).77
the effective programs that involved multiple exercise mo-
dalities, the Söderman et al60 program only involved balance- Two studies examined the efficacy of the PEP program in re-
board training. ducing ACL injuries in female soccer players. Mandelbaum et
al42 examined adolescent girls and women aged 14 to 18 years
Adolescent female athletes seem to gain the most and found an 89% decrease (rate ratio = 0.11; 95% CI: 0.03,
I benefit from exercise-based knee injury prevention
programs.45,68,80 Two meta-analyses examined the
0.48) in ACL injuries compared to age- and skill-matched
control athletes in the first season of the PEP program, and
effect of age, finding that girls under 18 years of age have a a 74% decrease (rate ratio = 0.26; 95% CI: 0.09, 0.85) in the

a8 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

second season of use. Gilchrist et al19 examined college-aged basketball intervention group. Although this was not a sta-
women and found lower, but nonsignificant, differences in tistically significant difference in incidence (intervention,
rates of ACL injuries in their intervention (0.20/1000 athlete- 0.42 injuries/1000 AEs; control, 0.48 injuries/1000 AEs; P
exposures [AEs]) compared to their control (0.34/1000 AEs) = .17), it was a positive trend following their 6-week, pre-
group (P = .20).19 The results were similar (lower but nonsig- season, 60- to 90-minute plyometric-based program. Female
nificant rates) when they examined noncontact ACL injuries basketball players who performed their intervention had sig-
specifically (intervention, 0.06/1000 AEs; control, 0.19/1000 nificantly fewer noncontact knee injuries compared to con-
AEs). There was a higher rate, though not significant, of overall trol female basketball players (P = .02). In contrast, Pfeiffer
knee injuries in their intervention group (1.14/1000 AEs) com- et al54 observed a 4-fold greater risk of noncontact ACL injury
pared to their control group (1.10/1000 AEs, P = .86). in their intervention group compared to the control group
(intervention, 0.48 ACL injuries per 1000 AEs; control,
Studies that have examined female soccer and team 0.11/1000 AEs) following their 15- to 20-minute program
II handball players have shown effectiveness in reduc-
ing ACL injuries (soccer: odds ratio = 0.32; 95%
that was performed after training sessions.

CI: 0.19, 0.56; team handball: odds ratio = 0.54; 95% CI: Volleyball
0.30, 0.97).80 However, making direct comparisons of effec- No conclusions can be drawn with regard to exer-
tiveness between sports needs to be done with caution, be-
cause the exercise-based knee injury prevention programs
II cise-based knee injury prevention programs in fe-
male volleyball players. Two studies included
used in each cohort were not identical. volleyball players, but neither study observed the outcome of
interest (serious knee injury or ACL injury) in either the in-
Team Handball tervention or the control group.29,54
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Olsen et al49 found significant reductions in acute


II knee injuries (relative risk = 0.45; 95% CI: 0.25,
0.81) and knee ligament injuries (relative risk =
Evidence Synthesis
There is evidence of important benefits of exercise-based
0.20; 95% CI: 0.06, 0.70) in 16- to 17-year-old male and fe- knee injury prevention programs, including reduction of
male team handball athletes after implementing an exercise- risk for knee and ACL injuries, with little risk of adverse
based knee injury prevention program. However, they noted events and minimal cost. However, the guideline develop-
no change in meniscal injuries (relative risk = 0.27; 95% CI: ment group identified gaps in evidence and recommends that
0.06, 1.28). researchers and clinicians should further evaluate the efficacy
of exercise-based knee injury prevention programs in men of
Achenbach et al1 found significant reductions in various ages playing sports. Additionally, researchers and cli-
J Orthop Sports Phys Ther 2018.48:A1-A42.

II severe (injuries that cause 28 or more days of ab-


sence from sport) knee injuries (odds ratio = 0.11;
nicians should further evaluate the efficacy of exercise-based
knee injury prevention programs in basketball and volleyball
95% CI: 0.01, 0.90; P = .02) in 15- to 17-year-old male and athletes. Although large-scale prospective trials or RCTs are
female team handball athletes. costly, the benefits of identifying programs effective in reduc-
ing knee injuries in various sports outweigh these financial
In female team handball players, Myklebust et al46 costs.
II did not find a significant decrease in ACL injuries
after performing an exercise-based knee injury pre- Recommendations
vention program for 2 seasons. However, when comparing Clinicians, coaches, parents, and athletes should
teams that were compliant with the program (performed the
intervention 15 or more times over the course of the season,
A implement exercise-based knee injury prevention
programs prior to athletic training sessions/prac-
with at least 75% of players participating) to the teams that tices or games in female athletes to reduce the risk of ACL
were not compliant, they found a significant decrease in ACL injuries, especially in female athletes younger than 18 years
injuries among the compliant elite team handball athletes of age. Programs that should be implemented include PEP,
(odds ratio = 0.06; 95% CI: 0.01, 0.54). Sportsmetrics, Knäkontroll, HarmoKnee, and those used by
Olsen et al49 and Petersen et al.52
Basketball
There is conflicting evidence on the effectiveness of Soccer players, especially women, should use ex-
II exercise-based knee injury prevention programs in
female basketball players. Hewett et al29 observed
A ercise-based knee injury prevention programs to
reduce the risk of severe knee and ACL injuries.
fewer knee ligament injuries (sprain/tear leading to greater Programs that could be beneficial for preventing severe
than 5 consecutive days of absence from sport) in their female knee injuries include PEP, Knäkontroll, and HarmoKnee.

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a9
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

Programs that could be beneficial for specifically preventing ing exercises failed to reduce ACL injuries (odds ratio = 1.02;
ACL injuries include those used by Caraffa et al 5 and 95% CI: 0.63, 1.64).67
Sportsmetrics.
Programs without balance training components
Male and female team handball players, particu- II (Sugimoto et al67: odds ratio = 0.34; CI: 0.20,
B larly those 15 to 17 years of age, should implement
exercise-based knee injury prevention programs.
0.56; Yoo et al80: odds ratio = 0.27; CI: 0.14, 0.49)
are effective in preventing ACL injuries in women. There
Programs that could be beneficial for preventing knee inju- are differing results regarding whether programs with bal-
ries include those used by Olsen et al49 and Achenbach et al.1 ance training components are effective (Sugimoto et al 67:
odds ratio = 0.59; CI: 0.42, 0.83; Yoo et al80: odds ratio =
0.63; CI: 0.37, 1.09). Taylor et al72 found that as the dura-
OBJECTIVE tion of time within a program spent performing balance
Describe the evidence for components, dosage, and delivery exercises increased, the protective effect of the program
of exercise-based knee injury prevention programs. decreased.

Evidence One program described by Söderman et al60 was included in


Components all 3 meta-analyses examining the components of preven-
Exercise-based injury prevention programs are ef- tion programs.67,72,80 Söderman et al60 only included balance
I fective in reducing ACL injuries in young women
when the programs incorporate multiple exercise
exercises and observed a greater rate of ACL injuries in the
intervention group.
components.67 Programs with more than 1 component re-
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sulted in ACL injury reductions (odds ratio = 0.32; 95% CI: Sadoghi et al57 performed a meta-regression to de-
0.22, 0.46). In contrast, programs with only a single exercise
component did not result in a significant reduction of injuries
II termine the factors that influence the effect of an
exercise-based knee injury prevention program in
(odds ratio = 1.15; 95% CI: 0.70, 1.89).67 women. They found that use of balance boards (P = .71), use
of video assistance (P = .91), duration of follow-up (P = .44),
Exercise-based knee injury prevention programs in and year of study publication (P = .36) did not influence a
I women that include proximal control exercises,
such as trunk/core strengthening and stability ex-
program’s ACL injury risk reduction.

ercises, led to significantly lower ACL injury rates (odds ratio Dosage and Delivery
= 0.33; 95% CI: 0.23, 0.47). In contrast, programs that did Gagnier et al18 performed a meta-analysis including
J Orthop Sports Phys Ther 2018.48:A1-A42.

not include proximal control exercises did not reduce injury


rates (odds ratio = 0.95; 95% CI: 0.60, 1.50).67
I men and women that indicated that programs with
a longer duration (greater than 14 months; inci-
dence rate ratio estimate = 0.41; 95% CI: 0.20, 0.84; P =.01),
Programs that incorporate both plyometric and more hours of training per week (0.75 hours or more per
II strengthening components are more effective at
reducing ACL injuries in women than programs
week; incidence rate ratio estimate = 0.38; 95% CI: 0.18,
0.77; P<.01), higher compliance (64% or greater; incidence
without both of these components.64,67,80 Stevenson et al64 rate ratio estimate = 0.39; 95% CI: 0.17, 0.89; P = .03), and
noted that studies that have demonstrated statistically sig- no participant dropout (incidence rate ratio estimate = 0.30;
nificant decreases in ACL injuries have all included strength- 95% CI: 0.15, 0.62; P<.01) were more effective at reducing
ening, flexibility, and plyometric components in their ACL injury incidence than programs that did not have these
programs (PEP, Sportsmetrics, and the program used by qualities.
Myklebust et al46),19,29,42 and only 1 program with a plyometric
component (the KLIP program used after training sessions Sugimoto et al66 performed a meta-analysis and
and games)54 has not resulted in a decrease in ACL injuries.
When strength and plyometrics are examined separately,
I subgroup analysis on clinical trials and evaluated
potential dosage effects of exercise-based injury
Sugimoto et al67 found that there was no significant differ- prevention training for ACL injury reduction in female
ence in ACL injury risk between programs with and without athletes. Exercise-based injury prevention programs with
plyometric components. However, when comparing pro- a high volume during the season (30 or more minutes per
grams with and without strengthening components, there week) had an odds ratio of 0.32 (95% CI: 0.19, 0.52) in
was a significant reduction in the number of ACL injuries reducing ACL injuries, compared to those with moderate
only in those programs with strengthening exercises (odds (15-30 minutes per week: odds ratio = 0.46; 95% CI: 0.21,
ratio = 0.32; 95% CI: 0.23, 0.46). Those without strengthen- 1.03) and low volumes (up to 15 minutes per week: odds

a10 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

ratio = 0.66; 95% CI: 0.43, 0.99). Programs that lasted 20 Compliance
minutes or less per session had an odds ratio of 0.61 (95% Sugimoto et al69 performed a meta-analysis of stud-
CI: 0.41, 0.90) in reducing ACL injuries, whereas pro-
grams that lasted longer than 20 minutes per session had
I ies involving female soccer, basketball, volleyball,
and team handball athletes, concluding that higher
an odds ratio of 0.35 (95% CI: 0.23, 0.53). Exercise-based rates of compliance with exercise-based injury prevention
injury prevention programs implemented multiple times programs were associated with lower rates of ACL injury in-
per week had an odds ratio of 0.35 (95% CI: 0.23, 0.53) in cidence among adolescent female athletes. The authors
reducing ACL injuries compared to programs that only found that when compliance was dichotomized (greater than
used training once a week, which had an odds ratio of 0.62 versus less than 42.5% overall compliance rate*), the inci-
(95% CI: 0.41, 0.94). dence rate in the high-compliance group was 73% lower (in-
cidence rate ratio = 0.27; 95% CI: 0.07, 0.80). When divided
Donnell-Fink et al9 examined men and women, into tertiles (greater than 66.6%, 33.3%-66.6%, less than
I comparing preseason-only and preseason-plus-in-
season programs to in-season-only programs, and
33.3% overall compliance), the high-compliance group had
82% lower ACL injury incidence (incidence rate ratio = 0.18;
found lower risk for knee injuries when preseason was in- 95% CI: 0.02, 0.77) than the medium- and low-compliance
cluded (preseason/preseason-plus-in-season incidence rate groups. The authors reported that a potential inverse dose-
ratio = 0.24; in-season-only rate ratio = 0.75; no CIs pre- response relationship exists between compliance with an
sented; P<.01). They did not find a significant result with this exercise-based injury prevention program and the incidence
same comparison for ACL injuries specifically (preseason/ of ACL injury in adolescent female athletes. *Overall compli-
preseason-plus-in-season incidence rate ratio = 0.32; in- ance rate was defined as the attendance rate multiplied by the
season-only rate ratio = 0.57; P = .33).9 compliance rate, with attendance rate defined as the number
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of participants who completed the minimum amount of ses-


In women, exercise-based knee injury prevention programs sion criteria in the study divided by the total number of par-
that began in the preseason and continued throughout the ticipants in the intervention group. Compliance rate was
season were effective (odds ratio = 0.54; 95% CI: 0.30, 0.97) defined as the number of sessions completed in the study
in reducing ACL injuries.80 Programs in-season only (odds divided by the maximum number of sessions offered to the
ratio = 0.32; 95% CI: 0.17, 0.59) had a lower odds ratio than intervention group.
programs in the preseason and in-season. Programs in the
preseason only (odds ratio = 0.35; 95% CI: 0.10, 1.21) were Studies of female soccer players, with data adjusted
not effective in reducing ACL injuries.80 II for compliance, found greater knee injury incidence
reductions in athletes who were compliant with the
J Orthop Sports Phys Ther 2018.48:A1-A42.

Sugimoto et al68 performed a meta-regression ex- exercise-based prevention programs.35,77 Kiani et al,35 using
I amining the “synergistic effects” of components of
exercise-based knee injury prevention programs
the HarmoKnee program, found a 77% lower incidence of
knee injuries (rate ratio = 0.23; 95% CI: 0.04, 0.83) and a
that they deemed key to optimizing ACL injury prevention. 90% lower incidence of noncontact knee injuries (rate ratio
They grouped age in tertiles (14-18 years, 18-20 years, 20 = 0.10; 95% CI: 0.00, 0.70). These reductions in knee injury
years or older), dosage was dichotomized (20 minutes or less risk decreased further when they were adjusted for compli-
per session, greater than 20 minutes per session), frequency ance (removal of 3 teams that performed the intervention
was dichotomized (once per week, multiple times per week), with less than 75% compliance, leaving 45 teams in the inter-
number of exercises was dichotomized (programs made up vention group). Athletes who were compliant with the Har-
of only 1 exercise component, programs made up of multiple moKnee program had an 83% reduction in knee injury
components), and verbal feedback to athletes on their form incidence (rate ratio = 0.17; 95% CI: 0.04, 0.64) and a 94%
was dichotomized (verbal feedback given, no verbal feed- decrease in noncontact knee injuries (rate ratio = 0.06; 95%
back). Points were assigned to groups based on previously CI: 0.01, 0.46).
reported odds ratios, with higher points given to groupings
that demonstrated lower odds ratios (greater ACL injury re- Waldén et al,77 using the Knäkontroll program in a
duction). Groups with the highest points were those aged 14
to 18 years, programs greater than 20 minutes in duration,
II cluster RCT, found an overall 64% decrease in ACL
injury incidence (rate ratio = 0.36; 95% CI: 0.15,
programs performed multiple times per week, and programs 0.85) in their intervention group compared to controls, but
with multiple exercise components. The results indicated an when they examined only their compliant players (defined as
odds ratio of 0.83 (β1 = –0.29; 95% CI: –0.33, –0.03; P = players having performed the intervention once per week on
.03), or 17% lower odds of sustaining an ACL injury if one of average), they found an 83% reduction in ACL injury rate
these highest-point groups was present. (rate ratio = 0.17; 95% CI: 0.05, 0.57). They also found that

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a11
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

compliant players had an 82% reduction in the rate of severe Evidence


knee injuries (rate ratio = 0.18; 95% CI: 0.07, 0.45) and a Grindstaff et al24 performed a systematic review to
47% reduction in the rate of acute knee injuries (rate ratio =
0.53; 95% CI: 0.30, 0.94).
I determine the number of athletes needed to treat
and the relative risk reduction in noncontact ACL
injuries associated with exercise-based knee injury prevention
Hägglund et al26 performed a subanalysis on the same RCT.77 programs. The sample included female soccer, basketball, and
Teams and players in the intervention group (184 teams, team handball athletes using 5 different prevention programs
2471 players) were stratified into tertiles of compliance (low, that varied in their exercise components. Frequency of training
intermediate, and high) based on their mean number of ranged from 3 times per week in the preseason to 1 to 3 times
weekly injury prevention program training sessions during per week during the season. They reported that to prevent 1
the season. High player compliance (mean, 89% compliance noncontact ACL injury during a sports season, 89 athletes
rate) resulted in an 88% reduction in ACL injury rate com- (95% CI for number needed to benefit: 66, 136) would have to
pared with low compliance (mean, 63% compliance rate). participate in a prevention program. The relative risk reduc-
Intermediate compliance (mean, 82% compliance rate) and tion for noncontact ACL injuries was 70% (95% CI: 54%,
high compliance reduced acute knee injury by 72% to 90% 80%) in athletes involved in a prevention program.
compared to low compliance. Low-compliance players had
higher rates of ACL injuries than the control players. An updated systematic review was published by

Evidence Synthesis
I Sugimoto et al,70 examining 12 studies (including all
5 studies reviewed by Grindstaff et al24), to determine
There is evidence of important benefits of exercise-based the effectiveness of exercise-based injury prevention programs
knee injury prevention programs, including reduction of risk designed to reduce ACL injury risk and noncontact ACL injury
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for knee and/or ACL injuries, with little risk of adverse events risk in female athletes. Sugimoto et al70 reported that to
and minimal cost. prevent 1 ACL injury during a sports season, 120 athletes (95%
CI for number needed to benefit: 74, 316) would need to par-
Recommendations ticipate in an exercise-based knee injury prevention program.
Exercise-based knee injury prevention programs The relative risk reduction for ACL injury was 43.8% (95% CI:
A used for women should incorporate multiple
components, proximal control exercises, and a
28.9%, 55.5%) in athletes involved in the prevention pro-
grams. Over the course of 1 season, to prevent 1 noncontact
combination of strength and plyometric exercises. ACL injury, 108 athletes (95% CI for number needed to ben-
efit: 86, 150) would have to participate in an exercise-based
Exercise-based knee injury prevention programs knee injury prevention program, with a relative risk reduction
J Orthop Sports Phys Ther 2018.48:A1-A42.

A should involve training multiple times per week,


training sessions that last longer than 20 minutes,
for noncontact ACL injury of 73.4% (95% CI: 62.5%, 81.1%)
in athletes involved in the prevention programs.
and training volumes that are longer than 30 minutes per week.
Lewis et al38 performed a cost analysis of 4 hypo-
Clinicians, coaches, parents, and athletes should I thetical strategies for implementing exercise-based
A start exercise-based knee injury prevention
programs in the preseason and continue performing
ACL injury prevention programs across Australia.
Using a prevention program similar to those in the litera-
the program throughout the regular season. ture,19,32,53,54 performed 3 times per week for 20 minutes and
supervised by coaches and medical staff, the study examined
Clinicians, coaches, parents, and athletes must ensure the resulting costs if implemented across Australia in 12- to
A high compliance with exercise-based knee injury
prevention programs, particularly in female athletes.
25-year-olds involved in high-risk sports, 18- to 25-year-olds
involved in high-risk sports, 12- to 17-year-olds involved in
high-risk sports, or all adolescents aged 12 to 17 years in-
Exercise-based knee injury prevention programs volved in any sport. High-risk sports were defined as rugby,
B may not need to incorporate balance exercises,
and balance should not be the sole component of
Australian rules football, netball, soccer, basketball, and ski-
ing. The authors found that the implementation strategy in-
a program. volving training 12- to 25-year-olds involved in high-risk
sports had the highest break-even value (the future health
care costs avoided) of $693 per person, followed by training
OBJECTIVE 18- to 25-year-olds in high-risk sports (break-even cost,
Provide suggestions for implementation of exercise-based $401), 12- to 17-year-olds in high-risk sports ($370), and all
knee injury prevention programs. 12- to 17-year-olds in sports ($102). The analysis also found

a12 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

that the strategy of training 12- to 25-year-olds in high-risk ACL injury; 95% CI: 73, 303), but a slightly higher relative
sports would prevent the most ACL injuries, with the lowest risk reduction of 48.2% (95% CI: 22%, 65%), compared to
number needed to treat, as well as prevent the highest num- coach-led programs, which had a number needed to benefit
ber of future knee injuries and total knee replacements (pre- of 131 (95% CI: 98, 196) and a relative risk reduction of
vented 3764 ACL injuries [number needed to treat, 27], 842 58.4% (95% CI: 40%, 71%).
knee osteoarthritis cases, and 584 total knee replacements
per 100 000 treated). Training 18- to 25-year-olds in high- Evidence Synthesis
risk sports prevented the next largest number of ACL injuries There is no increase in risk of adverse events when all ath-
and resulted in the smallest number needed to treat (pre- letes perform prevention programs compared to only athletes
vented 2303 ACL injuries [number needed to treat, 43], 511 screened as high risk, and there is no harm in performing
osteoarthritis cases, and 353 total knee replacements per prevention programs. Although cost may minimally increase
100 000 treated), followed by 12- to 17-year-olds in high-risk (depending on the program) as more athletes participate, the
sports (prevented 2021 ACL injuries [number needed to small increase in program costs is likely outweighed by long-
treat, 49], 457 osteoarthritis cases, and 317 total knee re- term health care costs and by the reduction in ACL injuries.
placements per 100 000 treated), and 12- to 17-year-olds in
all sports (prevented 526 ACL injuries [number needed to Recommendation
treat, 190], 119 osteoarthritis cases, and 83 total knee re- Clinicians, coaches, parents, and athletes should
placements per 100 000 treated). A implement exercise-based knee injury prevention
programs in all young athletes, not just those ath-
Swart et al71 performed a cost-effectiveness analysis letes identified through screening as being at high risk for
II on prevention and screening programs for ACL in- ACL injury, to optimize the numbers needed to treat while
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juries in young athletes who participated in pivoting reducing costs.


and cutting sports. They reported that an exercise-based ACL
injury prevention program performed by all athletes could re- For the greatest reduction in future medical costs
duce the incidence of ACL injury from 3% per season to 1.1%
per season, while a screening program that targeted high-risk
A and prevention of ACL injuries, osteoarthritis, and
total knee replacements, clinicians, coaches, par-
athletes could reduce ACL injury incidence from 3% per sea- ents, and athletes should encourage implementation of ex-
son to 1.8% per season. On a per-case basis, the average cost of ercise-based ACL injury prevention programs in athletes 12
the universal training strategy was $100 lower than no train- to 25 years of age and involved in sports with a high risk of
ing and $25 lower than the screening and training strategy. ACL injury.
J Orthop Sports Phys Ther 2018.48:A1-A42.

Pfile and Curioz55 performed a number-needed-to- Clinicians, coaches, parents, and athletes should
II treat analysis examining exercise-based ACL injury
prevention programs led by coaches versus pro-
B support implementation of exercise-based knee in-
jury prevention programs led by either coaches or
grams led by what they termed a mixed leadership group (ie, a group of coaches and medical professionals.
coaches, physical therapists, and/or athletic trainers). Pro-
grams led by a mixed leadership group had a lower number The recommendations made in this guideline are summa-
needed to benefit (120 athletes needed to treat to prevent 1 rized in FIGURES 1 and 2.

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a13
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

Evidence-Based Knee Injury Prevention Programs

All athletes regardless of age, sex, sport

Programs for reducing all knee injuries include 11+ and FIFA 11, HarmoKnee, and Knäkontroll; and those used by Emery and Meeuwisse,14 Goodall
et al,20 Junge et al,34 LaBella et al,36 Malliou et al,41 Olsen et al,49 Pasanen et al,51 Petersen et al,52 and Wedderkopp et al78
Programs for reducing ACL injuries include HarmoKnee, Knäkontroll, Prevent Injury and Enhance Performance (PEP), and Sportsmetrics; and those
used by Caraffa et al,5 Heidt et al,27 LaBella et al,36 Myklebust et al,46 Olsen et al,49 and Petersen et al52

Female athletes (especially those under Soccer players Team handball players
18 years of age)
Specific populations

PEP, Sportsmetrics, Knäkontroll, Programs that could be beneficial for Olsen et al,49 Achenbach et al1
HarmoKnee, Olsen et al,49 preventing knee injuries: PEP,
Petersen et al52 Knäkontroll, and HarmoKnee
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Programs that could be beneficial for


preventing ACL injuries: Caraffa et al,5
Sportsmetrics

Dosage and Delivery


Programs should involve multiple components, have a session duration greater than 20 minutes, have a weekly volume greater than 30 minutes,
start in the preseason and continue through the regular season, and be performed with high compliance
J Orthop Sports Phys Ther 2018.48:A1-A42.

Implementation
All young athletes, not just those screened as high risk, particularly athletes aged 12 to 25 years participating in high-risk sports (defined as rugby,
Australian rules football, netball, soccer, basketball, and skiing)

FIGURE 1. Treatment algorithm based on clinical practice guideline findings. The exercise-based knee injury prevention programs heading summarizes the programs observed
to be effective when studied across populations. Below the exercise-based knee injury prevention programs heading are the specific populations. These 2 groups (exercise-
based knee injury prevention and specific populations) are not mutually exclusive; all programs found in the specific populations area are also found in the exercise-based knee
injury prevention area. However, the program listed for specific populations may be more effective or may have been studied in detail in that particular group. The dosage and
delivery and implementation sections provide a summary of recommendations on how programs should be set up and executed.

Flexibility (dynamic Running Strength Core Plyometrics


stretches) • Forward running • Double-leg squat • Prone plank • Single-leg hopping,
• Quadriceps • Backward running • Single-leg squat • Bridges anterior/posterior
• Hamstrings • Zigzag running, forward • Lunges • “Ice skaters”
• Hip adductors and backward • Nordic hamstring • Jump to header or catch
• Hip flexors • Bounding exercise ball over head
• Calf (depending on sport)

FIGURE 2. Exercises included in the 2 videos are available at https://www.jospt.org/doi/suppl/10.2519/jospt.2018.0303.

a14 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

Planned Strategies and Tools to Support the Dissemination


TABLE 1
and Implementation of This Clinical Practice Guideline

Tool Strategy
“Perspectives for Patients” and videos for clinicians, coaches, and athletes Patient-oriented guideline summary available on www.jospt.org and
www.orthopt.org (FIGURES 1 and 2, TABLE 2)
Mobile applications of guideline-based exercises for patients/clients, athletes, Marketing and distribution of app using www.orthopt.org
coaches, and health care practitioners
Clinician’s quick-reference guide Summary of guideline recommendations available on www.orthopt.org
Read-for-credit continuing education content Continuing education content available for physical therapists and athletic
trainers from JOSPT
Webinar-based educational offerings for health care practitioners Guideline-based instruction available for practitioners on www.orthopt.org
Mobile and web-based applications for health care practitioner training Marketing and distribution of app using www.orthopt.org
Non-English versions of the guidelines and guideline Development and distribution of translated guidelines and tools to JOSPT’s
implementation tools international partners and global audience via www.jospt.org

TABLE 2 Contents of Programs Frequently Referenced in the CPG


Downloaded from www.jospt.org by 140.213.58.240 on 12/16/18. For personal use only.

Area/Study or Program Equipment Needed Time for Each Activity Activities/Muscles Included in Program
Flexibility
HarmoKnee None Muscle activation: approximately 2 minutes • Standing calf stretch
of total time, holding position and • Standing quadriceps stretch
contracting the muscle for approximately • Half-kneeling hamstring stretch
4 seconds, focusing on “finding” your • Half-kneeling hip flexor stretch
muscles. Stretching is only recommend- • Butterfly adductor stretch
ed in cases of limited range of motion • Modified figure-of-four stretch
PEP None 50 yd each, 30 × 2 repetitions each • Calf stretch
• Quadriceps stretch
• Figure-of-four hamstring stretch
• Inner thigh stretch
• Hip flexor stretch
J Orthop Sports Phys Ther 2018.48:A1-A42.

Sportsmetrics None 3 sets of 30 seconds each, or 2 laps • Gastrocnemius


• Soleus
• Quadriceps
• Hamstrings
• Hip flexors
• Iliotibial band/lower back
• Posterior deltoids
• Latissimus dorsi
• Pectorals/biceps
Running
HarmoKnee None As part of warm-up, 10 minutes total, • Jogging (4-6 minutes)
separate times for each • Backward jogging on toes (1 minute)
• High-knee skipping (30 seconds)
• Defensive pressure technique: sliding slowly, zigzag backward (30 seconds)
• Alternating forward zigzag running and pressure technique: zigzag backward (2 minutes)
KLIP None 4 phases, each lasting 2 wk. Time/repeti- • Agility: “W” drill
tions for each exercise not specified • Agility: figure-of-eights
• Agility: left/right cuts
Olsen et al49 None 30 seconds and 1 repetition each • Jogging
• Backward running with sidesteps
• Forward running with knee lifts and heel kicks
• Sideways running with crossovers (“carioca”)
• Sideways running with arms lifted (“parade”)
• Forward running with trunk rotations
• Forward running with intermittent stops
• Speed run
• Bounding strides
• Planting and cutting
Table continues on page A16.

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a15
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

TABLE 2 Contents of Programs Frequently Referenced in the CPG (continued)

Area/Study or Program Equipment Needed Time for Each Activity Activities/Muscles Included in Program
PEP None 50 yd each, 2 repetitions each • Jog from line to line of soccer field (cone to cone)
• Shuttle run (side to side)
• Backward running
• Shuttle run with forward/backward running (40 yd)
• Diagonal runs (40 yd)
• Bounding run (45-50 yd)
Sportsmetrics None 3 sets of 30 seconds each, or 2 laps • Skipping
• Side shuffle
• Cool-down walk (2 minutes)
Balance
Achenbach et al1 Ball optional Not specified • Standing on 1 leg with eyes closed, try to destabilize the partner by pressing against
their body
Caraffa et al5 Rectangular wobble 2.5 minutes, 4 times a day for each exercise • Phase 1: single-leg stance, no board
board, round • Phase 2: single-leg stance on rectangular board (on 45°)
balance board, • Phase 3: single-leg stance on round board
combined round/ • Phase 4: single-leg stance on a combined round and rectangular board
rectangular • Phase 5: single-leg stance on a BAPS board
board, BAPS
board
Myklebust et al46 Balance mat, wobble Not specified • Single-leg stance on mat with throw
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board • Standing on mat with partner, try to push partner off


• Jump onto mat while catching ball, then turn 180°
• Double-leg balance on wobble board with throwing
• Double-leg squat on wobble board
• Single-leg squat on wobble board
• Single-leg stance on wobble board with bounding ball
• Two players on wobble boards: try to push the other off
Olsen et al49 Balance mat or 4 minutes and 2 × 90 seconds each • Passing the ball (2-leg stance)
wobble board • Squats (1- or 2-leg stance)
• Passing the ball (1-leg stance)
• Bouncing the ball with eyes closed
• Pushing each other off balance
Strength
J Orthop Sports Phys Ther 2018.48:A1-A42.

Achenbach et al1 None Not specified • Nordic hamstring eccentric strengthening


Caraffa et al5 Step Not specified (prior to balance training) • Anterior step-up
• Posterior step-up
HarmoKnee None 1 minute each • Lunges in place (alternating anterior lunges)
• Nordic hamstring eccentric strengthening
• Single-leg squat with toe raise
Knäkontroll Ball 3 sets, 8-15 repetitions. Each exercise with 4 • Level 1: double-leg squat
levels of difficulty • Level 2: double-leg squat with heel raise
• Level 3: double-leg squat with ball over head
• Level 4: double-leg squat with ball held in front of body
• Level 5 (partner exercise): partner stands next to you approximately 1 m away, facing
opposite directions; hold ball between you with one hand and the other hand on hip;
apply slight pressure on ball while performing knee squat
• Level 1: forward walking lunge
• Level 2: forward lunge with ball, lateral trunk rotation
• Level 3: forward lunge with ball over head
• Level 4: lateral lunge
• Leve 5 (partner exercise): partner stands in front of you 5-10 m away; perform
forward lunge while making throw-in with ball
• Level 1: single-leg squat
• Level 2: single-leg squat with overhead ball
• Level 3: single-leg squat with off leg at differing positions
• Level 4: single-leg Romanian deadlift
• Level 5 (partner exercise): partner stands slightly oblique in front of you, and ball is
pressed between lateral sides of feet of nonsupporting legs
Olsen et al49 None 2 minutes and 3 × 10 repetitions each • Squats to 80° of knee flexion
• Nordic hamstring eccentric strengthening
Table continues on page A17.

a16 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

TABLE 2 Contents of Programs Frequently Referenced in the CPG (continued)

Area/Study or Program Equipment Needed Time for Each Activity Activities/Muscles Included in Program
PEP None Varies based on exercise • Walking lunges, 20 yd × 2 sets
• Russian hamstring, 3 sets × 10 repetitions or 30 seconds
• Single toe raises, 30 repetitions each side
Sportsmetrics Weight equipment/ 1 set of 12 repetitions for upper body, 1 set of • Back hyperextension
machines 15 repetitions for trunk and lower body • Leg press
• Calf raise
• Pullover
• Bench press
• Latissimus dorsi pull-down
• Forearm curl
Core stability
Achenbach et al1 None Not specified • Plank
• Side plank
HarmoKnee None 1 minute each • Sit-ups
• Plank on elbows
• Bridging
Knäkontroll None 15-30 seconds • Level 1: prone plank on knees
• Level 2: prone plank on toes
• Level 3: prone plank on toes with lateral step
• Level 4: side plank
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• Level 5 (partner exercise): plank with partner holding feet


• Level 1: bridge, double leg
• Level 2: bridge, single leg
• Level 3: bridge, single leg on ball
• Level 4: bridge, single leg with hop
• Level 5 (partner exercise): partner stands with flexed knees and supports heel of one
of your feet in her hands
Sportsmetrics Weight equipment 1 set of 12 repetitions for upper body, 1 set of • Abdominal curl
15 repetitions for trunk and lower body
Plyometrics
Achenbach et al1 None Not specified • Multidirectional single-leg jumps
• “Ice-skater” jumps
• Jump run
J Orthop Sports Phys Ther 2018.48:A1-A42.

HarmoKnee Ball optional 30 seconds each • Forward and backward double-leg jumps
• Lateral single-leg jumps
• Forward and backward single-leg jumps
• Double-leg jump with or without ball
KLIP None 4 phases, each lasting 2 wk. Time/repeti- • Straight jumps
tions for each exercise not specified • Tuck jumps
• Standing broad jump
• Bound in place
• 180° jump
• Single-leg lateral leaps
• 45° lateral leaps
• Combination jumps
• Single-leg forward hops
• Single-leg 45° lateral hops
• Single-leg forward hops × 3
Knäkontroll None 3 sets, 5-15 repetitions • Level 1: single-leg forward/backward hops
• Level 2: double-leg lateral jumps, landing on single leg
• Level 3: take a few quick steps on same spot and make short jump straight forward,
landing on 1 foot
• Level 4: take a few quick steps on same spot and make short jump, but change direc-
tion and jump to 1 side (90° turn); alternate sides
• Level 5 (partner exercise): partner stands in front of you approximately 5 m away;
make 2-legged jump while heading soccer ball and land on 2 legs
Myklebust et al46 None Not specified • Run and plant
• Double-leg jump forward/backward; partner pushes player (perturbation)
• Jump shot (handball) from 30- to 40-cm box with soft landing
• Step off 30- to 40-cm box with single-leg landing
Table continues on page A18.

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a17
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

TABLE 2 Contents of Programs Frequently Referenced in the CPG (continued)

Area/Study or Program Equipment Needed Time for Each Activity Activities/Muscles Included in Program
Olsen et al49 None 4 minutes and 5 × 30 seconds each • Jump-shot landings
• Forward jumps
PEP Cones (5-15 cm tall) 20 repetitions or 30 seconds each • Lateral hops over cone
• Forward/backward hops over cone
• Single-leg hops over cone
• Vertical jumps with headers
• Scissors jump
Sportsmetrics None Varies based on exercise • Wall jumps (20 seconds, progressing to 30 seconds)
• Tuck jumps (20 seconds, progressing to 30 seconds)
• Broad jumps, stick (hold) landing (5-10 repetitions)
• Squat jumps (10 seconds, progressing to 25 seconds)
• Double-legged cone jumps (30 seconds/30 seconds side to side and back to front)
• 180° jumps (20-25 seconds)
• Bounding in place (20-25 seconds)
• Jump, jump, jump, vertical jump (5-8 repetitions)
• Bounding for distance (1-2 runs)
• Scissors jump (30 seconds)
• Hop, hop, stick landing (5 repetitions per leg)
• Step, jump up, down, vertical (5-10 repetitions)
• Mattress jumps (30 seconds/30 seconds side to side and back to front)
• Single-legged jumps for distance (5 repetitions per leg)
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• Jump into bounding (3-4 runs)


Abbreviations: BAPS, Biomechanical Ankle Platform System; CPG, clinical practice guideline; KLIP, Knee Ligament Injury Prevention; PEP, Prevent Injury
and Enhance Performance.

TABLE 3 Programs Included in This Guideline

Program/Study Study Type Participants Duration Effect Harms


Achenbach et al1 Block RCT Intervention, n = 168 One team handball season Significant reduction in severe (injuries that caused >28 None
J Orthop Sports Phys Ther 2018.48:A1-A42.

Control, n = 111 d of absence from sport) knee injuries


Male and female team handball Control-group severe knee injury incidence, 0.33/1000 h
players aged 15-17 y Intervention-group severe knee injury incidence,
0.04/1000 h
Odds ratio = 0.11 (95% CI: 0.01, 0.90; P = .02)
Caraffa et al5 Cohort n = 600 semi-professional and 30 days during preseason (20 Significant difference in injury incidence between None
amateur soccer players in minutes every day) intervention and control teams (P<.01)
Umbri and Marche, Italy Intervention teams, 0.15 ACL injuries per season
Age and sex not provided Control teams, 1.15 ACL injuries per season
HarmoKnee
Kiani et al35 Cohort Intervention, n = 777 4 months (approximately 20-25 Knee injuries: intervention incidence, 0.04/1000 h; con- None
Control, n = 729 minutes, twice per week, trol, 0.20/1000 h; unadjusted rate ratio = 0.23 (95%
Female soccer players aged during preseason, and once CI: 0.04, 0.83); rate ratio adjusted for compliance =
13-19 y per week during the regular 0.17 (95% CI: 0.04, 0.64)
season) Noncontact knee injuries: intervention, 0.01/1000 h; con-
trol, 0.15/1000 h; unadjusted rate ratio = 0.10 (95%
CI: 0.00, 0.70); rate ratio adjusted for compliance =
0.06 (95% CI: 0.01, 0.46)
There were no ACL injuries in the intervention group
Table continues on page A19.

a18 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

TABLE 3 Programs Included in This Guideline (continued)

Program/Study Study Type Participants Duration Effect Harms


KLIP
Pfeiffer et al54 Cohort Intervention, n = 577 Throughout high school season Incidence of noncontact ACL injuries in the control None
Control, n = 862 (20 minutes, but the authors group, 0.078/1000 AEs; intervention group,
Female high school–aged soc- did not report the recom- 0.167/1000 AEs
cer, basketball, or volleyball mended number of times Overall, there was a nonsignificant increase in odds of
players per week) ACL injury in the intervention groups (odds ratio =
2.05; 95% CI: 0.21, 21.7; P>.05)
There were no noncontact ACL injuries in the volleyball
control group and in the soccer and volleyball
intervention groups
There were more noncontact ACL injuries in the basket-
ball intervention group (0.476/1000 AEs) than in the
basketball control group (0.111/1000 AEs)
Knäkontroll
Waldén et al77 Stratified Intervention, n = 2479 Throughout soccer season (15 64% reduction in ACL injuries in the intervention group None
RCT Control, n = 2085 minutes, twice per week) (rate ratio = 0.36; 95% CI: 0.15, 0.85; P = .02)
Female soccer players aged When adjusted for compliance: 83% reduction in ACL
13-17 y injuries (rate ratio = 0.17; 95% CI: 0.05, 0.57; P<.01),
82% reduction in severe knee injury (rate ratio = 0.18;
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95% CI: 0.07, 0.45; P<.01), 47% reduction in all acute


knee injuries (rate ratio = 0.53; 95% CI: 0.30, 0.94;
P = .03)
Myklebust et al46 Cohort Control season, n = 942 Throughout team handball Control-season ACL injury incidence, 0.14/1000 playing None
First intervention season, n season, including preseason hours
= 855 (15 minutes, 3 times per First-intervention-season ACL injury incidence,
Second intervention season, week during preseason and 0.13/1000 playing hours
n = 850 once per week during regular Second-intervention-season ACL injury incidence,
Female Norwegian team hand- season) 0.06/1000 playing hours
ball league players; mean No significant difference in injury rate (odds ratio = 0.52;
age not provided 95% CI: 0.15, 1.82; P = .31)
When adjusted for compliance, there was a significant
J Orthop Sports Phys Ther 2018.48:A1-A42.

decrease in injury risk in the elite division (odds ratio


= 0.06; 95% CI: 0.01, 0.54; P = .01)

Olsen et al49 Cluster Intervention, n = 958 Through one 8-month team Significant reduction in all injuries (relative risk = 0.49; None
RCT Control, n = 879 handball season (15-20 95% CI: 0.39, 0.63; P<.01)
Female team handball players minutes, 15 consecutive train- Acute knee injuries: relative risk = 0.45; 95% CI: 0.25,
aged 16-17 y ing sessions at the start of the 0.81; P<.01
season, followed by once per Number of athletes needed to treat to prevent 1 acute
week for the remainder of the knee injury was 43
season) Significant reduction in knee ligament injuries (relative
risk = 0.20; 95% CI: 0.06, 0.70; P = .01)
Nonsignificant reduction in meniscal injuries (relative
risk = 0.27; 95% CI: 0.06, 1.28; P = .10)
PEP
Gilchrist et al19 Cluster Control, n = 852 12 weeks through collegiate soc- Overall, no significant difference in injury rates for all One player tripped
RCT Intervention, n = 583 cer season (15-20 minutes, 3 knee injuries (P = .86) or ACL injuries (P = .20) during the lateral
NCAA Division I female soccer times per week) The intervention group had a lower ACL injury rate in hops and had a
players; mean age, 19.9 y practices (P = .01), a lower late-season ACL injury tibial and fibular
rate (P = .03), a lower rate of noncontact ACL injuries fracture, after
in those who reported a history of ACL injury (P = which the cone
.05), and there was no difference between groups in height used was
the injury rates during games (P = .62), early in the adjusted to be
season (P = .93), or among those with no history of shorter
prior ACL injury (P = .43)
Table continues on page A20.

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a19
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

TABLE 3 Programs Included in This Guideline (continued)

Program/Study Study Type Participants Duration Effect Harms


Mandelbaum Cohort Year 1: intervention, n = 1041; Throughout soccer season (20 Overall incidence of ACL injuries for the intervention None
et al42 control, n = 1905 minutes, but the authors did group was 0.09/1000 AEs, and for the control group
Year 2: intervention, n = 844; not report recommended was 0.49/1000 AEs, over the 2-y study
control, n = 1931 number of times per week) Rate ratio = 0.18, P<.01
Female soccer players aged When broken down by year: year 1, 89% reduction in ACL
14-18 y injuries (rate ratio = 0.11, P<.01); year 2, 74% reduc-
tion in risk (relative risk = 0.26, P<.01)
Sportsmetrics
Hewett et al29 Cohort Female intervention, n = 366 6 weeks during preseason (60- Trained females had a significantly lower rate of severe Not reported
Female control, n = 463 90 minutes, 3 times per week) knee injuries (incidence, 0.12/1000 AEs) than un-
Male control, n = 434 trained females (incidence, 0.43/1000 AEs; P = .05)
High school–aged soccer, Untrained females had a higher rate of severe knee
basketball, and volleyball injuries than males (incidence, 0.09/1000 AEs; P =
players .03), but there was no difference in rate of severe knee
injuries between trained females and males (P = .86)
The trained female group (incidence, 0) had a signifi-
cantly lower rate of noncontact knee injuries com-
pared to the untrained female (incidence, 0.35/1000
AEs; P = .01) and untrained male groups (incidence,
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0.05/1000 AEs; P = .01)


Abbreviations: ACL, anterior cruciate ligament; AE, athlete-exposure; CI, confidence interval; CPG, clinical practice guideline; KLIP, Knee Ligament Injury
Prevention; NCAA, National Collegiate Athletic Association; PEP, Prevent Injury and Enhance Performance; RCT, randomized controlled trial.

Links to Studies Included in the Meta-analyses and Systematic


TABLE 4
Reviews That Met the CPG Inclusion Criteria

Program Link
Achenbach et al1 https://www.ncbi.nlm.nih.gov/pubmed/29058022
https://doi.org/10.1007/s00167-017-4758-5
J Orthop Sports Phys Ther 2018.48:A1-A42.

Caraffa et al5 http://www.ncbi.nlm.nih.gov/pubmed/8963746


https://link.springer.com/content/pdf/10.1007/BF01565992.pdf
HarmoKnee http://harmoknee.com/
http://www.ncbi.nlm.nih.gov/pubmed/20065198
http://archinte.jamanetwork.com/article.aspx?articleid=481521
KLIP http://www.ncbi.nlm.nih.gov/pubmed/15574070
https://journals.lww.com/jbjsjournal/Abstract/2006/08000/Lack_of_Effect_of_a_Knee_Ligament_Injury.12.aspx
Knäkontroll App available on Apple or Android platforms:
https://itunes.apple.com/se/app/knakontroll/id573826071?mt=8
https://play.google.com/store/apps/details?id=se.rf.sisu&hl=en
https://www.ncbi.nlm.nih.gov/pubmed/22556050
http://www.bmj.com/content/344/bmj.e3042.full.pdf+html
Myklebust et al46 http://www.ncbi.nlm.nih.gov/pubmed/12629423
https://onlinelibrary.wiley.com/doi/pdf/10.1034/j.1600-0838.2003.00341.x
Olsen et al49 http://www.ncbi.nlm.nih.gov/pubmed/12629423
https://onlinelibrary.wiley.com/doi/pdf/10.1034/j.1600-0838.2003.00341.x
PEP https://www.youtube.com/watch?v=t_yz7yWLo5o
http://la84.org/a-practical-guide-to-the-pep-program/
https://www.ncbi.nlm.nih.gov/pubmed/15888716
http://ajs.sagepub.com/content/36/8/1476.full.pdf+html
http://ajs.sagepub.com/content/33/7/1003.full.pdf+html
Sportsmetrics http://sportsmetrics.org/
https://www.ncbi.nlm.nih.gov/pubmed/10569353
http://ajs.sagepub.com/content/27/6/699.full.pdf+html
Table continues on page A21.

a20 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

Links to Studies Included in the Meta-analyses and Systematic


TABLE 4
Reviews That Met the CPG Inclusion Criteria (continued)

Program Link
11+* http://fifamedicinediploma.com/lessons/prevention-fifa-11/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3867089/
Emery and Meeuwisse14* https://www.ncbi.nlm.nih.gov/pubmed/20547668
http://bjsm.bmj.com/content/44/8/555.abstract
Goodall et al20* https://www.ncbi.nlm.nih.gov/pubmed/22924758
http://dx.doi.org/10.1080/17457300.2012.717085
Heidt et al27* https://www.ncbi.nlm.nih.gov/pubmed/11032220
http://ajs.sagepub.com/content/28/5/659.abstract
Junge et al34* https://www.ncbi.nlm.nih.gov/pubmed/12238997
http://ajs.sagepub.com/content/30/5/652.abstract
LaBella et al37* https://www.ncbi.nlm.nih.gov/pubmed/18832542
http://cpj.sagepub.com/content/48/3/327.long
Malliou et al41* https://www.ncbi.nlm.nih.gov/pubmed/15446640
http://journals.sagepub.com/doi/abs/10.2466/pms.99.1.149-154
Pasanen et al51* https://www.ncbi.nlm.nih.gov/pubmed/18595903
http://www.bmj.com/content/337/bmj.a295
Petersen et al52* https://www.ncbi.nlm.nih.gov/pubmed/23189409
Söderman et al60* https://www.ncbi.nlm.nih.gov/pubmed/11147154
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https://link.springer.com/article/10.1007%2Fs001670000147
Wedderkopp et al78* https://www.ncbi.nlm.nih.gov/pubmed/9974196
https://onlinelibrary-wiley-com.e.bibl.liu.se/doi/pdf/10.1111/j.1600-0838.1999.tb00205.x
Abbreviations: CPG, clinical practice guideline; KLIP, Knee Ligament Injury Prevention; PEP, Prevent Injury and Enhance Performance.
*The individual studies of these programs did not meet the CPG inclusion criteria.
J Orthop Sports Phys Ther 2018.48:A1-A42.

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a21
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

AFFILIATIONS AND CONTACTS


AUTHORS Medicine Group Houston Methodist Orthopedics and Mashpee, MA
Amelia J.H. Arundale, PT, PhD Santa Monica, CA Sports Medicine and
Research Assistant bmandelbau@aol.com Houston, TX Adjunct Assistant Clinical Professor
Biomechanics and Movement Science mtcharpentier@houstonmethodist.org Program in Physical Therapy
David Scalzitti, PT, PhD MGH Institute of Health Professions
Program
Assistant Professor John DeWitt, DPT, ATC Charlestown, MA
University of Delaware
Department of Physical Therapy Director of Physical Therapy Residency jzachazewski@verizon.net
Newark, DE
George Washington University and Fellowship Programs
and
Washington, DC The Ohio State University
Postdoctoral Researcher
scalzitt@gwu.edu Columbus, OH GUIDELINES EDITORS
Department of Medical and Health Christine M. McDonough, PT, PhD
Sciences john.dewitt@osumc.edu
Holly Silvers-Granelli, PT, PhD ICF-Based Clinical Practice Guidelines
Division of Physiotherapy Editor
Physical Therapist Amanda Ferland, DPT
Linköping University Academy of Orthopaedic Physical
Velocity Physical Therapy Clinical Faculty
Linköping, Sweden Therapy, APTA, Inc
Santa Monica, CA Tongji University/USC Division of
arundale@udel.edu La Crosse, WI
and Biokinesiology and Physical Therapy
Research Assistant Orthopaedic Physical Therapy and
Mario Bizzini, PT, PhD
Biomechanics and Movement Science Residency Assistant Professor of Physical Therapy
Research Associate and Orthopaedic
Program and School of Health and Rehabilitation
and Sports Physical Ttherapist
University of Delaware Spine Rehabilitation Fellowship Sciences
Schulthess Clinic
Newark, DE Shanghai, China University of Pittsburgh
Zurich, Switzerland
hollysilverspt@gmail.com AmandaFerland@incarehab.com Pittsburgh, PA
Mario.bizzini@f-marc.com
cmm295@pitt.edu
Airelle Giordano, DPT Lynn Snyder-Mackler, PT, ScD, FAPTA Jennifer S. Howard, ATC, PhD
Alumni Distinguished Professor Assistant Professor Guy G. Simoneau, PT, PhD, ATC, FAPTA
Assistant Professor
ICF-Based Clinical Practice Guidelines
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Department of Physical Therapy Department of Physical Therapy Department of Health and Exercise
Science Editor
University of Delaware University of Delaware
Beaver College of Health Sciences Academy of Orthopaedic Physical
Newark, DE Newark, DE
Appalachian State University Therapy, APTA, Inc
aohunter@udel.edu smack@udel.edu
Boone, NC La Crosse, WI
Tim Hewett, PhD howardjs@appstate.edu and
Director of Biomechanics and Sports REVIEWERS Professor
Medicine Research Roy D. Altman, MD David Killoran, PhD Physical Therapy Department
Mayo Sports Medicine Center Professor of Medicine Patient/Consumer Representative Marquette University
Departments of Orthopedics, Physical Division of Rheumatology and ICF-Based Clinical Practice Guidelines Milwaukee, WI
Medicine and Rehabilitation, Immunology Academy of Orthopaedic Physical guy.simoneau@marquette.edu
and Physiology and Biomedical David Geffen School of Medicine Therapy, APTA, Inc
University of California at Los Angeles La Crosse, WI Joseph J. Godges, DPT, MA
Engineering
Los Angeles, CA and ICF-Based Clinical Practice Guidelines
The Mayo Clinic
J Orthop Sports Phys Ther 2018.48:A1-A42.

journals@royaltman.com Professor Emeritus Editor


Rochester, MN
Loyola Marymount University Academy of Orthopaedic Physical
Hewett.timothy@mayo.edu
Paul Beattie, PT, PhD Los Angeles, CA Therapy, APTA, Inc
David Logerstedt, PT, PhD Clinical Professor david.killoran@lmu.edu La Crosse, WI
Assistant Professor Division of Rehabilitative Sciences and
Department Physical Therapy Arnold School of Public Health Leslie Torburn, DPT Adjunct Associate Professor of Clinical
University of the Sciences University of South Carolina Principal and Consultant Physical Therapy
Philadelphia, PA Columbia, SC Silhouette Consulting, Inc Division of Biokinesiology and Physical
d.logerstedt@usciences.edu pbeattie@gwm.sc.edu Sacramento, CA Therapy at the Ostrow School of
torburn@yahoo.com Dentistry
Bert Mandelbaum, MD Marie Charpentier, DPT, ATC, LAT University of Southern California
Orthopaedic Surgeon Coordinator of Sports and Athletic James Zachazewski, DPT Los Angeles, CA
Santa Monica Orthopaedic & Sports Training Residency Programs Cape Cod Rehabilitation and Fitness godges@usc.edu

ACKNOWLEDGMENTS: The authors acknowledge the contributions of George Washington University Himmelfarb Health Science librar-
ian Tom Harrod for his guidance and assistance in the design and implementation of the literature search; Nicholas Ienni and Sarah
Aoyama, Doctor of Physical Therapy students at George Washington University, for screening articles; Dean Caswell, PT, ATC, AT/L,
China Football Academy and Olympic Football Club of Beijing Sport University; Michael Lau, DPT, Co-Founder of The Prehab Guys,
Joe Godges, DPT, MA, University of Southern California, and Maury Hayashida, DPT, Motus Enterprises, LLC for their assistance in
creating the videos; Casson Demmon from The Make Studio for video production; and Demetri Dimitriadis, DPT, Talaria Physical
Therapy and Wellness, Christian Hintz, DPT, Fairview - Institute for Athletic Medicine, Kelli Baggett, DPT, University of Illinois Chicago
for their assistance in creating the "Contents of Programs Frequently Referenced in the CPG" Table.

a22 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

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@ MORE INFORMATION
org/10.1136/bjsports-2011-090895
71. Swart E, Redler L, Fabricant PD, Mandelbaum BR, Ahmad CS, Wang YC. WWW.JOSPT.ORG

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a25
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX A

SEARCH STRATEGY FOR ALL DATABASES SEARCHED

PubMed
Search Strategy Search Limits
(Sports [MeSH] OR Athletes [MeSH] OR Exercise [MeSH] OR English only, then Clinical Trial, Clinical Trial Phase I, Clinical Trial
Athletic Injuries [MeSH]) AND ((Knee Injuries [MeSH]) OR Phase II, Clinical Trial Phase III, Clinical Trial Phase IV, Comparative
((Wounds and Injuries [MeSH] OR injur* [TW]) AND (ACL Study, Controlled Clinical Trial, Evaluation Studies, Guideline, Intro-
[TW] OR Anterior Cruciate Ligament* [TW] OR Anterior ductory Journal Article, Journal Article, Meta-Analysis, Multicenter
Cruciate Ligament [MeSH]))) AND (Risk Reduction Behav- Study, Observational Study, Practice Guideline, Pragmatic Clinical
ior [MeSH] OR Prevent* [TW] OR Predict* [TW]) Trial, Randomized Control Trial, Systematic Reviews, Twin Study

Scopus
Search Strategy Search Limits
(TITLE-ABS-KEY (Sport*) OR TITLE-ABS-KEY (Athlet*) OR TITLE-ABS-KEY English only, limit to Article, Review, and Article in Press
(Exercise) OR TITLE-ABS-KEY (Athletic Injur*)) AND ((TITLE-ABS-KEY
(Knee Injur*)) OR ((TITLE-ABS-KEY(Wound*) OR TITLE-ABS-KEY
(Injur*)) AND (TITLE-ABS-KEY (Anterior Cruciate Ligament) OR TITLE-
ABS-KEY (ACL)))) AND (TITLE-ABS-KEY (Risk Reduction) OR TITLE-
ABS-KEY (Prevent*) OR TITLE-ABS-KEY (Predict*))
Downloaded from www.jospt.org by 140.213.58.240 on 12/16/18. For personal use only.

SPORTDiscus
Search Strategy Search Limits
((TI (Sport*) OR AB (Sport*) OR (DE “Sports”)) OR (TI (Athlet*) OR AB English, English Abstract Only, Peer-Reviewed, Academic
(Athlet*) OR (DE “ATHLETICS”)) OR (TI (Exercise) OR AB (Exercise) Journal
OR (DE “EXERCISE”)) OR (TI (Athletic Injur*) OR AB (Athletic Injur*)))
AND ((TI (Knee Injur*) OR AB (Knee Injur*)) OR ((((TI (Wound*) OR AB
(Wound*)) OR (TI (Injur*) OR AB (Injur*))) OR (DE “WOUNDS & inju-
ries”)) AND ((TI (Anterior Cruciate Ligament) OR AB (Anterior Cruciate
Ligament) OR (DE “ANTERIOR cruciate ligament”)) OR (TI (ACL) OR
J Orthop Sports Phys Ther 2018.48:A1-A42.

AB (ACL))))) AND ((TI (Risk Reduction) OR AB (Risk Reduction)) OR


(TI (Prevent*) OR AB (Prevent*) OR (DE “PREVENTION”)) OR (TI (Pre-
dict*) OR AB (Predict*)))

CINAHL
Search Strategy Search Limits
((TI (Sport*) OR AB (Sport*) OR (MH “Sports+”)) OR (TI (Athlet*) OR English Language checkbox, Adolescent, Adult, Middle-
AB (Athlet*)) OR (TI (Exercise) OR AB (Exercise) OR (MH “Exercise+”)) Aged, Aged 65+. Aged 80+, Clinical Trial, Corrected
OR (TI (Athletic Injur*) OR AB (Athletic Injur*) OR (MH “Athletic Inju- Article, Journal Article, Practice Guidelines, Research,
ries+”))) AND ((TI (Knee Injur*) OR AB (Knee Injur*) OR (MH “Knee Systematic Review
Injuries+”)) OR ((TI (Wound*) OR AB (Wound*) OR TI (Injur*) OR AB
(Injur*) OR (MH “Wounds and Injuries+”)) AND (TI (Anterior Cruciate
Ligament) OR AB (Anterior Cruciate Ligament) OR TI (ACL) OR AB
(ACL) OR (MH “Anterior Cruciate Ligament+”)))) AND ((TI (Risk Reduc-
tion) OR AB (Risk Reduction)) OR (TI (Prevent*) OR AB (Prevent*)) OR
(TI (Predict*) OR AB (Predict*)))

Cochrane
Search Strategy Search Limits
((Sport*) OR (Athlet*) OR (Exercise) OR (Athletic Injur*)) AND (((Knee Cochrane Reviews - ALL, Other Reviews, Trials, Technology
Injur*)) OR (((Wound*) OR ( Injur*)) AND ((Anterior Cruciate Ligament) Assessments, Economic Evaluations
OR (ACL)))) AND ((Risk Reduction) OR (Prevent*) OR (Predict*))

a26 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX B

SEARCH DATES AND RESULTS

Initial Search
Database Date Conducted Results, n
PubMed 3/31/2015 812
Scopus 3/31/2015 2083
SPORTDiscus 3/31/2015 511
CINAHL 3/31/2015 275
Cochrane Library 3/31/2015 145
Cochrane reviews 6
Other reviews 12
Trials 126
Technology assessments 0
Economic evaluations 1
Total 3826
Total with duplicates removed 2623
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Search Update (2016)


Database Date Conducted Results, n
PubMed 4/1/2016 57
Scopus 4/1/2016 297
SPORTDiscus 4/1/2016 96
CINAHL 4/1/2016 18
Cochrane Library 4/1/2016 14
Cochrane reviews 2
Other reviews 0
J Orthop Sports Phys Ther 2018.48:A1-A42.

Trials 12
Technology assessments 0
Economic evaluations 0
Total 482
Total with duplicates removed 341

Search Update (2017)


Database Date Conducted Results, n
PubMed 10/19/2017 129
Scopus 10/19/2017 508
SPORTDiscus 10/19/2017 94
CINAHL 10/19/2017 21
Cochrane Library 10/19/2017 44
Cochrane reviews 1
Other reviews 0
Trials 43
Technology assessments 0
Economic evaluations 0
Total 796
Total with duplicates removed 562

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a27
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX C

FLOW CHART OF LITERATURE REVIEW PROCESS

PubMed, Scopus, SPORTDiscus, CINAHL, and


Cochrane databases searched for articles
published before June 2015, n = 5104
• Original search (March 2015), n = 3826
• First search update (April 2016), n = 482
• Second search update (October 2017), n = 796
Total with duplicates removed, n = 3526
• Original search, n = 2623
• First search update, n = 341
• Second search update, n = 562

Articles screened and meeting criteria of full text,


published in English, and peer reviewed, n = 752 Excluded, n = 712
• Original search, n = 171 • Prevention program but not exercise
• First search update, n = 19 based, n = 63
• Second search update, n = 562 • Program not knee focused, n = 89
• Not written in English, n = 2
• Not full text, n = 7
• Not level I or II study, n = 81
• Article not on prevention, n = 425
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• Duplications not caught in earlier


Articles meeting inclusion/exclusion criteria, screening, n = 4
n = 40 • Risk factors for knee injury (not
injury incidence), n = 41
Articles identified through
reference lists, n = 45

Articles meeting inclusion/exclusion criteria,


n = 85 Excluded, n = 43
• Not exercise based, n = 2
• Not knee only, n = 13
J Orthop Sports Phys Ther 2018.48:A1-A42.

• Not meta-analysis/systematic
review/cohort study, n = 3
• Article not on prevention, n = 24
• Risk factors for knee injury, n = 1
Articles meeting inclusion/exclusion criteria,
n = 42

Excluded based on quality-assessment


score, n = 9

Included articles, n = 33

a28 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX D

INCLUDED ARTICLES 1999;27:699-706. https://doi.org/10.1177/036354659902700


Achenbach L, Krutsch V, Weber J, et al. Neuromuscular exercises 60301
prevent severe knee injury in adolescent team handball play- Kiani A, Hellquist E, Ahlqvist K, Gedeborg R, Michaëlsson K,
ers. Knee Surg Sports Traumatol Arthrosc. 2018;26:1901- Byberg L. Prevention of soccer-related knee injuries in teen-
1908. https://doi.org/10.1007/s00167-017-4758-5 aged girls. Arch Intern Med. 2010;170:43-49. https://doi.
Alentorn-Geli E, Mendiguchía J, Samuelsson K, et al. Preven- org/10.1001/archinternmed.2009.289
tion of non-contact anterior cruciate ligament injuries in Lewis DA, Kirkbride B, Vertullo CJ, Gordon L, Comans TA.
sports. Part II: systematic review of the effectiveness of Comparison of four alternative national universal anterior
prevention programmes in male athletes. Knee Surg Sports cruciate ligament injury prevention programme implementa-
Traumatol Arthrosc. 2014;22:16-25. https://doi.org/10.1007/ tion strategies to reduce secondary future medical costs.
s00167-013-2739-x Br J Sports Med. 2018;52:277-282. https://doi.org/10.1136/
Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo A. Prevention of bjsports-2016-096667
anterior cruciate ligament injuries in soccer. A prospective Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness
controlled study of proprioceptive training. Knee Surg Sports of a neuromuscular and proprioceptive training program in
Traumatol Arthrosc. 1996;4:19-21. https://doi.org/10.1007/ preventing anterior cruciate ligament injuries in female ath-
BF01565992 letes: 2-year follow-up. Am J Sports Med. 2005;33:1003-1010.
Donnell-Fink LA, Klara K, Collins JE, et al. Effectiveness of https://doi.org/10.1177/0363546504272261
knee injury and anterior cruciate ligament tear prevention
Michaelidis M, Koumantakis GA. Effects of knee injury primary
programs: a meta-analysis. PLoS One. 2015;10:e0144063.
prevention programs on anterior cruciate ligament injury rates
Downloaded from www.jospt.org by 140.213.58.240 on 12/16/18. For personal use only.

https://doi.org/10.1371/journal.pone.0144063
in female athletes in different sports: a systematic review.
Gagnier JJ, Morgenstern H, Chess L. Interventions designed Phys Ther Sport. 2014;15:200-210. https://doi.org/10.1016/j.
to prevent anterior cruciate ligament injuries in adoles- ptsp.2013.12.002
cents and adults: a systematic review and meta-analysis.
Myer GD, Ford KR, Brent JL, Hewett TE. Differential neuromuscu-
Am J Sports Med. 2013;41:1952-1962. https://doi.
lar training effects on ACL injury risk factors in “high-risk” ver-
org/10.1177/0363546512458227
sus “low-risk” athletes. BMC Musculoskelet Disord. 2007;8:39.
Gilchrist J, Mandelbaum BR, Melancon H, et al. A random- https://doi.org/10.1186/1471-2474-8-39
ized controlled trial to prevent noncontact anterior
cruciate ligament injury in female collegiate soccer play- Myer GD, Sugimoto D, Thomas S, Hewett TE. The influence of
ers. Am J Sports Med. 2008;36:1476-1483. https://doi. age on the effectiveness of neuromuscular training to reduce
org/10.1177/0363546508318188 anterior cruciate ligament injury in female athletes: a meta-
J Orthop Sports Phys Ther 2018.48:A1-A42.

analysis. Am J Sports Med. 2013;41:203-215. https://doi.


Grimm NL, Jacobs JC, Jr., Kim J, Denney BS, Shea KG. Ante- org/10.1177/0363546512460637
rior cruciate ligament and knee injury prevention programs
for soccer players: a systematic review and meta-analysis. Myklebust G, Engebretsen L, Braekken IH, Skjølberg A, Olsen OE,
Am J Sports Med. 2015;43:2049-2056. https://doi. Bahr R. Prevention of anterior cruciate ligament injuries in fe-
org/10.1177/0363546514556737 male team handball players: a prospective intervention study
over three seasons. Clin J Sport Med. 2003;13:71-78.
Grimm NL, Shea KG, Leaver RW, Aoki SK, Carey JL. Efficacy and
degree of bias in knee injury prevention studies: a systematic Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R. Exer-
review of RCTs. Clin Orthop Relat Res. 2013;471:308-316. cises to prevent lower limb injuries in youth sports: cluster
https://doi.org/10.1007/s11999-012-2565-3 randomised controlled trial. BMJ. 2005;330:449. https://doi.
org/10.1136/bmj.38330.632801.8F
Grindstaff TL, Hammill RR, Tuzson AE, Hertel J. Neuromuscular
control training programs and noncontact anterior cruciate Pfeiffer RP, Shea KG, Roberts D, Grandstrand S, Bond L. Lack
ligament injury rates in female athletes: a numbers-needed- of effect of a knee ligament injury prevention program on
to-treat analysis. J Athl Train. 2006;41:450-456. the incidence of noncontact anterior cruciate ligament in-
Hägglund M, Atroshi I, Wagner P, Waldén M. Superior compliance jury. J Bone Joint Surg Am. 2006;88:1769-1774. https://doi.
with a neuromuscular training programme is associated with org/10.2106/JBJS.E.00616
fewer ACL injuries and fewer acute knee injuries in female Pfile KR, Curioz B. Coach-led prevention programs are effective
adolescent football players: secondary analysis of an RCT. in reducing anterior cruciate ligament injury risk in female
Br J Sports Med. 2013;47:974-979. https://doi.org/10.1136/ athletes: a number-needed-to-treat analysis. Scand J Med Sci
bjsports-2013-092644 Sports. 2017;27:1950-1958. https://doi.org/10.1111/sms.12828
Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect Sadoghi P, von Keudell A, Vavken P. Effectiveness of anterior cruciate
of neuromuscular training on the incidence of knee injury ligament injury prevention training programs. J Bone Joint Surg
in female athletes. A prospective study. Am J Sports Med. Am. 2012;94:769-776. https://doi.org/10.2106/JBJS.K.00467

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a29
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX D

Stevenson JH, Beattie CS, Schwartz JB, Busconi BD. Assess- cruciate ligament injury in female athletes: a critical review of
ing the effectiveness of neuromuscular training programs in relative risk reduction and numbers-needed-to-treat analyses.
reducing the incidence of anterior cruciate ligament injuries Br J Sports Med. 2012;46:979-988. https://doi.org/10.1136/
in female athletes: a systematic review. Am J Sports Med. bjsports-2011-090895
2015;43:482-490. https://doi.org/10.1177/0363546514523388 Swart E, Redler L, Fabricant PD, Mandelbaum BR, Ahmad CS,
Sugimoto D, Myer GD, Barber Foss KD, Hewett TE. Dosage effects Wang YC. Prevention and screening programs for anterior cru-
of neuromuscular training intervention to reduce anterior ciate ligament injuries in young athletes: a cost-effectiveness
cruciate ligament injuries in female athletes: meta- and sub- analysis. J Bone Joint Surg Am. 2014;96:705-711. https://doi.
group analyses. Sports Med. 2014;44:551-562. https://doi. org/10.2106/JBJS.M.00560
org/10.1007/s40279-013-0135-9 Taylor JB, Waxman JP, Richter SJ, Shultz SJ. Evaluation of the
Sugimoto D, Myer GD, Barber Foss KD, Hewett TE. Specific effectiveness of anterior cruciate ligament injury prevention
exercise effects of preventive neuromuscular training inter- programme training components: a systematic review and
vention on anterior cruciate ligament injury risk reduction meta-analysis. Br J Sports Med. 2015;49:79-87. https://doi.
in young females: meta-analysis and subgroup analysis. Br org/10.1136/bjsports-2013-092358
J Sports Med. 2015;49:282-289. https://doi.org/10.1136/ van Beijsterveldt AM, Krist MR, Schmikli SL, et al. Effectiveness
bjsports-2014-093461 and cost-effectiveness of an injury prevention programme
Sugimoto D, Myer GD, Barber Foss KD, Pepin MJ, Micheli LJ, for adult male amateur soccer players: design of a cluster-
Hewett TE. Critical components of neuromuscular training randomised controlled trial. Inj Prev. 2011;17:e2. https://doi.
Downloaded from www.jospt.org by 140.213.58.240 on 12/16/18. For personal use only.

to reduce ACL injury risk in female athletes: meta-regression org/10.1136/ip.2010.027979


analysis. Br J Sports Med. 2016;50:1259-1266. https://doi. Waldén M, Atroshi I, Magnusson H, Wagner P, Hägglund M.
org/10.1136/bjsports-2015-095596 Prevention of acute knee injuries in adolescent female
Sugimoto D, Myer GD, Bush HM, Klugman MF, Medina McKeon football players: cluster randomised controlled trial. BMJ.
JM, Hewett TE. Compliance with neuromuscular training and 2012;344:e3042. https://doi.org/10.1136/bmj.e3042
anterior cruciate ligament injury risk reduction in female ath- Yoo JH, Lim BO, Ha M, et al. A meta-analysis of the effect of neu-
letes: a meta-analysis. J Athl Train. 2012;47:714-723. https:// romuscular training on the prevention of the anterior cruciate
doi.org/10.4085/1062-6050-47.6.10 ligament injury in female athletes. Knee Surg Sports Trau-
Sugimoto D, Myer GD, McKeon JM, Hewett TE. Evaluation of the matol Arthrosc. 2010;18:824-830. https://doi.org/10.1007/
effectiveness of neuromuscular training to reduce anterior s00167-009-0901-2
J Orthop Sports Phys Ther 2018.48:A1-A42.

a30 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX E

QUALITY-ASSESSMENT SCORES

Systematic Reviews and Meta-analyses: AMSTAR Checklist*


Study 1 2 3 4 5 6 7 8 9 10 11 Quality†
Alentorn-Geli et al2 x x x x x 5
Chang and Lai6 x x x x 4
Donnell-Fink et al9 x x x x x x x x 8
Gagnier et al18 x x x x x x x x x 9
Grimm et al22 x x x x x x x x 8
Grimm et al23 x x x x x x x 7
Grindstaff et al24 x x x x x x x 7
Hewett and Myer30 x x 2
Hewett et al28 x x x 3
Michaelidis and Koumantakis43 x x x x x 5
Myer et al45 x x x x x x 6
Noyes and Barber-Westin48 x x x x 4
Noyes and Barber Westin47 x x 2
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Padua and Marshall50 x x x 3


Pfile and Curioz55 x x x x x x x 7
Sadoghi et al57 x x x x x x x 7
Stevenson et al64 x x x x x x 6
Stojanovic and Ostojic65 x x x x 4
Sugimoto et al68 x x x x x x x x x 9
Sugimoto et al69 x x x x x x x 7
Sugimoto et al66 x x x x x x x x 8
Sugimoto et al67 x x x x x x x x 8
J Orthop Sports Phys Ther 2018.48:A1-A42.

Sugimoto et al70 x x x x x x x x x 9
Taylor et al72 x x x x x x x x 8
Yoo et al80 x x x x x 5
Abbreviation: AMSTAR, A Measurement Tool to Assess Systematic Reviews.
*Yes/no. Items: 1, Was an a priori design provided? 2, Was there duplicate study selection and data extraction? 3, Was a comprehensive literature search per-
formed? 4, Was the status of publication (ie, gray literature) used as an inclusion criterion? 5, Was a list of studies (included and excluded) provided? 6, Were
the characteristics of the included studies provided? 7, Was the scientific quality of the included studies assessed and documented? 8, Was the scientific quality
of the included studies used appropriately in formulating conclusions? 9, Were the methods used to combine the findings of studies appropriate? 10, Was the
likelihood of publication bias assessed? 11, Was the conflict of interest included?

What is your overall assessment of the methodological quality of this review? High quality, 8 or greater; acceptable, 5, 6, or 7; reject, 4 or less.

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Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX E

Randomized Controlled Trials: Physiotherapy Evidence Database Scale (PEDro)*


Study 1 2 3 4 5 6 7 8 9 10 11 Quality†
Achenbach et al1 x x x x x x 6
Gilchrist et al19 x x x x x x x x 8
Hägglund et al26 x x x x x 5
Olsen et a49 x x x x x x x x 8
van Beijsterveldt et al73 x x x x x x x x 8
Vescovi and VanHeest76 x x x x 4
Waldén et al77 x x x x x x x x 8
*Items: 1, Eligibility criteria were specified; 2, Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in
which treatments were received); 3, Allocation was concealed; 4, The groups were similar at baseline regarding the most important prognostic indicators; 5,
There was blinding of all subjects; 6, There was blinding of all therapists who administered the therapy; 7, There was blinding of all assessors who measured
at least 1 key outcome; 8, Measures of at least 1 key outcome were obtained from more than 85% of the subjects initially allocated to groups; 9, All subjects for
whom outcome measures were available received the treatment or control condition as allocated, or, where this was not the case, data for at least 1 key outcome
were analyzed by “intention to treat”; 10, The results of between-group statistical comparisons were reported for at least 1 key outcome; 11, The study provides
both point measures and measures of variability for at least 1 key outcome.

Quality rating: 8 or higher, high; 5, 6, or 7, acceptable; 4 or less, reject.

Cohort Studies: Scottish Intercollegiate Guidelines Network Checklist (SIGN)*


Study 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Quality†
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Caraffa et al5 x x x x x x x x x 9
Hewett et al29 x x x x x 5
Kiani et al35 x x x x x x x x x x x 11
LaBella et al37 x x x x 4
Mandelbaum et al42 x x x x x x x x 8
Myer et al44 x x x x x 5
Myklebust et al46 x x x x x x x 7
Pfeiffer et al54 x x x x x x 6
*Items: 1, The study addresses an appropriate and clearly focused question; 2, The 2 groups being studied are selected from source populations that are com-
J Orthop Sports Phys Ther 2018.48:A1-A42.

parable in all respects other than the factor under investigation; 3, The study indicates how many of the people asked to take part did so, in each of the groups
being studied; 4, The likelihood that some eligible subjects might have the outcome at the time of enrollment is assessed and taken into account in the analysis;
5, What percentage of individuals or clusters recruited into each arm of the study dropped out before the study was completed? 6, Comparison is made between
full participants and those lost to follow-up, by exposure status; 7, The outcomes are clearly defined; 8, The assessment of outcome is made blind to exposure
status (if the study is retrospective, this may not be applicable); 9, Where blinding was not possible, there is some recognition that knowledge of exposure status
could have influenced the assessment of outcome; 10, The method of assessment of exposure is reliable; 11, Evidence from other sources is used to demonstrate
that the method of outcome assessment is valid and reliable; 12, Exposure level or prognostic factor is assessed more than once; 13, The main potential con-
founders are identified and taken into account in the design and analysis; 14, Have confidence intervals been provided?

How well was the study done to minimize the risk of bias or confounding? Quality rating: 8 or higher, high; 5, 6, or 7, acceptable; 4 or less, reject.

Economic Analysis: Drummond Checklist*11


Question/Checklist Item Swart et al71 Lewis et al38
Was a well-defined question posed in answerable form?
Did the study examine both costs and effects of the service(s) or program(s)? x x
Did the study involve a comparison of alternatives? x x
Was a viewpoint for the analysis stated and was the study placed in any particular decision-making x x
context?
Was a comprehensive description of the competing alternatives given?
Were any relevant alternatives omitted? x
Was (should) a do-nothing alternative (be) considered? x
Was the effectiveness of the program or services established?
Was this done through a randomized, controlled clinical trial? If so, did the trial protocol reflect what
would happen in regular practice?
Table continues on page A33.

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Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX E

Question/Checklist Item Swart et al71 Lewis et al38


Were effectiveness data collected and summarized through a systematic overview of clinical studies? If x
so, were the search strategies and rules for inclusion or exclusion outlined?
Were observational data or assumptions used to establish effectiveness? If so, what are the potential x x
biases in results?
Were all the important and relevant costs and consequences for each alternative identified?
Was the range wide enough for the research question at hand? x x
Did it cover all relevant viewpoints? x x
Were the capital costs, as well as operating costs, included? x x
Were costs and consequences measured accurately in appropriate physical units?
Were the sources of resource utilization described and justified? x x
Were any of the identified items omitted from measurement? If so, does this mean that they carried no
weight in the subsequent analysis?
Were there any special circumstances that made measurement difficult? Were these circumstances
handled appropriately?
Were costs and consequences valued credibly?
Were the sources of all values clearly identified? x x
Were market values employed for changes involving resources gained or depleted? x
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Where market values were absent, or market values did not reflect actual values, were adjustments x
made to approximate market values?
Was the valuation of consequences appropriate for the question posed? x x
Were costs and consequences adjusted for differential timing?
Were costs and consequences that occur in the future “discounted” to their present values? x
Was any justification given for the discounted rate used? x
Was an incremental analysis of costs and consequences of alternatives performed?
Were the additional costs generated by one alternative over another compared to the additional effects, x
benefits, or utilities generated?
Was allowance made for uncertainty in the estimates of cost and consequences?
J Orthop Sports Phys Ther 2018.48:A1-A42.

If patient-level data on costs or consequences were available, were appropriate statistical analyses x x
performed?
If a sensitivity analysis was employed, was justification provided for the ranges or distributions of val- x x
ues, and the form of sensitivity analysis used?
Were the conclusions of the study sensitive to the uncertainty in the results, as quantified by the statis- x x
tical and/or sensitivity analysis?
Did the presentation and discussion of study results include all issues of concern to users?
Were the conclusions of the analysis based on some overall index or ratio of costs to consequences? If x x
so, was the index interpreted intelligently or in a mechanistic fashion?
Were the results compared with those of others who have investigated the same question? If so, were
allowances made for potential differences in study methodology?
Did the study discuss the generalizability of the results to other settings and patient/client groups? x
Did the study allude to, or take account of, other important factors in the choice or decision under x x
consideration?
Did the study discuss issues of implementation, such as feasibility of adopting the “preferred” program x x
given existing financial or other constraints, and whether any freed resources could be redeployed to
other worthwhile programs?
Quality score 21 20
*Only studies that met inclusion/exclusion criteria were reviewed for quality. There are studies referred to in this clinical practice guideline that did not meet
the inclusion/exclusion criteria themselves but receive mention because they are included in systematic reviews or meta-analyses that did meet the inclusion/
exclusion criteria, for example, Söderman et al.60

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Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX F

LEVELS OF EVIDENCE TABLE*


Pathoanatomic/Risk/
Clinical Course/
Intervention/ Prognosis/Differential Diagnosis/Diagnostic Prevalence of
Level Prevention Diagnosis Accuracy Condition/Disorder Exam/Outcomes
I Systematic review of Systematic review of Systematic review of Systematic review, Systematic review of
high-quality RCTs prospective cohort high-quality diagnos- high-quality cross- prospective cohort
High-quality RCT† studies tic studies sectional studies studies
High-quality prospec- High-quality diagnostic High-quality cross- High-quality prospec-
tive cohort study‡ study§ with validation sectional study║ tive cohort study
II Systematic review of Systematic review of Systematic review of ex- Systematic review of Systematic review
high-quality cohort retrospective cohort ploratory diagnostic studies that allows of lower-quality
studies study studies or consecu- relevant estimate prospective cohort
High-quality cohort Lower-quality prospec- tive cohort studies Lower-quality cross- studies
study‡ tive cohort study High-quality exploratory sectional study Lower-quality prospec-
Outcomes study or High-quality retrospec- diagnostic studies tive cohort study
ecological study tive cohort study Consecutive retrospec-
Lower-quality RCT¶ Consecutive cohort tive cohort
Outcomes study or
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ecological study
III Systematic reviews of Lower-quality retro- Lower-quality explor- Local nonrandom study High-quality cross-
case-control studies spective cohort study atory diagnostic sectional study
High-quality case- High-quality cross- studies
control study sectional study Nonconsecutive retro-
Lower-quality cohort Case-control study spective cohort
study
IV Case series Case series Case-control study … Lower-quality cross-
sectional study
V Expert opinion Expert opinion Expert opinion Expert opinion Expert opinion
J Orthop Sports Phys Ther 2018.48:A1-A42.

Abbreviation: RCT, randomized clinical trial.


*Adapted from Phillips et al56 (http://www.cebm.net/index.aspx?o=1025). See also APPENDIX G.

High quality includes RCTs with greater than 80% follow-up, blinding, and appropriate randomization procedures.

High-quality cohort study includes greater than 80% follow-up.
§
High-quality diagnostic study includes consistently applied reference standard and blinding.

High-quality prevalence study is a cross-sectional study that uses a local and current random sample or censuses.

Weaker diagnostic criteria and reference standards, improper randomization, no blinding, and less than 80% follow-up may add bias and threats to validity.

a34 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX G

PROCEDURES USED FOR ASSIGNING • Cohort study includes greater than 80% follow-up
LEVELS OF EVIDENCE • Diagnostic study includes consistently applied reference
• Level of evidence is assigned based on the study design using standard and blinding
the Levels of Evidence table (APPENDIX F), assuming high quality • Prevalence study is a cross-sectional study that uses a lo-
(eg, for intervention, randomized clinical trial starts at level I) cal and current random sample or censuses
- Acceptable quality (the study does not meet requirements
• Study quality is assessed using the critical appraisal tool, and
for high quality and weaknesses limit the confidence in the
the study is assigned 1 of 4 overall quality ratings based on the
accuracy of the estimate): downgrade 1 level
critical appraisal results
• Based on critical appraisal results
• Level of evidence assignment is adjusted based on the overall - Low quality: the study has significant limitations that sub-
quality rating: stantially limit confidence in the estimate: downgrade 2
- High quality (high confidence in the estimate/results): study levels
remains at assigned level of evidence (eg, if the randomized • Based on critical appraisal results
clinical trial is rated high quality, its final assignment is level - Unacceptable quality: serious limitations—exclude from con-
I). High quality should include: sideration in the guideline
• Randomized clinical trial with greater than 80% follow-up, • Based on critical appraisal results
blinding, and appropriate randomization procedures
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J Orthop Sports Phys Ther 2018.48:A1-A42.

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a35
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX H

EFFICACY OF EXERCISE-BASED KNEE INJURY PREVENTION PROGRAMS


Review/Included Articles Outcomes Examined Findings
Donnell-Fink et al9
Caraffa et al,5 Emery and Primary: incidence Primary: pooled incidence reduction ratio for knee injury prevention =
Meeuwisse,14 Gilchrist et of knee and ACL 0.731 (95% CI: 0.61, 0.87), pooled incidence reduction ratio for ACL in-
al,19 Goodall et al,20 Grooms injuries jury prevention = 0.493 (95% CI: 0.285, 0.854)
et al,25 Heidt et al,27 Hewett Secondary: subgroup Secondary subgroup analysis: age (dichotomized by high school aged or
et al,29 Junge et al,34 Kiani et analysis of knee and older than high school aged) not associated with knee or ACL injury
al,35 LaBella et al,37 Longo et ACL injuries reduction, knee injuries (high school incidence reduction ratio = 0.79,
al,40 Malliou et al,41 Mandel- Tertiary: incidence older than high school incidence reduction ratio = 0.58; P = .20), ACL
baum et al,42 Myklebust et of noncontact ACL injuries (high school incidence reduction ratio = 0.36, older than high
al,46 Olsen et al,49 Pasanen injuries school incidence reduction ratio = 0.58; P = .41)
et al,51 Petersen et al,52 Pfei- Programs during preseason or preseason plus in-season versus in-sea-
ffer et al,54 Söderman et al,60 son-only programs
Soligard et al,62 Steffen et Lower risk of knee injury in preseason/preseason plus in-season (inci-
al,63 van Beijsterveldt et al,74 dence reduction ratio = 0.24) than in-season only (incidence reduction
Waldén et al,77 Wedderkopp ratio = 0.75, P<.01), no difference for ACL injuries (preseason/pre-
et al78 season-plus-in-season incidence reduction ratio = 0.32, in-season-only
incidence reduction ratio = 0.57; P = .33)
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Tertiary: pooled incidence rate ratio for noncontact ACL injuries = 0.51
(95% CI: 0.30, 0.88)
Gagnier et al18
Caraffa et al,5 Ettlinger et al,16 Primary: overall ACL Primary: pooled incidence rate ratio = 0.49 (95% CI: 0.30, 0.79; P<.01),
Gilchrist et al,19 Heidt et al,27 injury incidence with some effects of heterogeneity
Hewett et al,29 Kiani et al,35 Secondary: subgroup Secondary subgroup analysis: pooled incidence rate ratio smaller (stron-
Mandelbaum et al,42 Mykle- analysis of ACL in- ger inverse association) for nonrandomized cohort studies (pooled
bust et al,46 Olsen et al,49 jury incidence incidence rate ratio = 0.38; 95% CI: 0.20, 0.70; P<.01), studies in the
Pasanen et al,51 Petersen et United States (pooled incidence rate ratio = 0.36; 95% CI: 0.15, 0.88; P
al,52 Pfeiffer et al,54 Söder- = .03), studies of longer duration (>14 mo) (pooled incidence rate ratio
J Orthop Sports Phys Ther 2018.48:A1-A42.

man et al,60 Steffen et al63 = 0.41; 95% CI: 0.20, 0.84; P = .01), studies with more hours of training
per week (>0.75 h) (pooled incidence rate ratio = 0.38; 95% CI: 0.18,
0.77; P<.01), studies that reported better compliance (>64%) (pooled
incidence rate ratio = 0.39; 95% CI: 0.17, 0.89; P = .03), studies that
reported no dropouts (pooled incidence rate ratio = 0.30; 95% CI: 0.15,
0.62; P<.01), and studies that included only soccer players (pooled
incidence rate ratio = 0.30; 95% CI: 0.16, 0.56; P<.01). Little difference,
though significant, for females (pooled incidence rate ratio = 0.51; 95%
CI: 0.28, 0.94; P = .03). No significant difference between those inter-
ventions that included plyometric exercises compared to those that did
not (no P value presented)
Sadoghi et al57
Caraffa et al,5 Gilchrist et al,19 Risk of ACL injury Risk differences reported in the component studies varied considerably
Heidt et al,27 Hewett et al,29 Numbers needed to treat ranged from 5 to 187
Mandelbaum et al,42 Peters- One study had a lower risk in controls
en et al,52 Petersen et al,53 Pooled risk ratio was 0.38 (95% CI: 0.20, 0.72; P<.01), indicating a signifi-
Pfeiffer et al,54 Söderman et cant decrease in risk in the intervention groups
al,60 Myklebust et al46 Stratified by sex: pooled risk ratio for women = 0.48 (95% CI: 0.26, 0.89;
P = .02) and for men = 0.15 (95% CI: 0.08, 0.28; P<.01)
Use of a balance board or video assistance, the duration of follow-up, or
year of publication did not affect the pooled risk ratio
Conducting the intervention during the preseason, compared to during the
playing season, reduced the risk by 19.1%, but this was not significant
Abbreviations: ACL, anterior cruciate ligament; CI, confidence interval.

a36 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX I

EFFICACY OF EXERCISE-BASED KNEE INJURY PREVENTION PROGRAMS IN MALE AND FEMALE PARTICIPANTS
Sex/Review/Included Articles Outcomes Examined Findings
Male
Alentorn-Geli et al2
Bencke et al,3 Caraffa et Reduction of ACL Two of 7 studies examined the effect of interventions on ACL injury rates: 1 found a
al,5 Cochrane et al,7 injury significant reduction in ACL injury rates,5 1 had no ACL injuries in either group (but
Dempsey et al,8 Don- did have a 72% decrease in lower extremity injury risk)25
nelly et al,10 Grooms et The quality of studies increased over time
al,25 Jamison et al33
Female
Grimm et al23
Brushøj et al,4 Ekstrand Knee and ACL injury Two of 10 studies showed a reduction in knee injuries13,49
et al,13 Emery incidence Four studies reported a nonsignificant increase in knee injuries in the intervention
and Meeuwisse,14 group14,15,19,61
Engebretsen et al,15 Two of 3 studies examining ACL injury incidence found decreases in number of inju-
Gilchrist et al,19 Olsen et ries, but none found a significant reduction19,49,60
al,49 Söderman et al,60 One study showed a nonsignificant increase in ACL injuries in the intervention
Soligard et al,61 Steffen et group60
al,63 Wedderkopp et al78 No evidence of publication bias
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Myer et al45
Gilchrist et al,19 Heidt et ACL injury incidence Overall, a significantly greater knee injury reduction in female athletes in intervention
al,27 Hewett et al,29 Kiani based on age groups compared to controls (odds ratio = 0.54; 95% CI: 0.35, 0.83)
et al,35 LaBella et al,36 Age dichotomized: under 18 y (odds ratio = 0.28; 95% CI: 0.18, 0.42; P<.01) and over
Mandelbaum et al,42 18 y (odds ratio = 0.84; 95% CI: 0.56, 1.26; P = .39)
Myklebust et al,46 Olsen Age in tertiles: those aged 14-18 y had an odds ratio of 0.28 (95% CI: 0.18, 0.42;
et al,49 Pasanen et al,51 P<.01), those aged 18-20 y had an odds ratio of 0.48 (95% CI: 0.21, 1.07; P = .07),
Petersen et al,52 Pfeiffer and those aged >20 y had an odds ratio of 1.01 (95% CI: 0.62, 1.64; P = .97)
et al,54 Söderman et al,60 No evidence of publication bias
Steffen et al,63 Waldén
et al77
J Orthop Sports Phys Ther 2018.48:A1-A42.

Stevenson et al64
Gilchrist et al,19 Heidt et ACL injury incidence Two of 10 programs achieved a statistically significant decrease in ACL injuries29,42
al,27 Hewett et al,29 Kiani One study had a significant decrease in the incidence of ACL injuries during prac-
et al,35 Mandelbaum et tices, late in the season, and in noncontact ACL injuries in those with a history of
al,42 Myklebust et al,46 prior ACL injuries19
Petersen et al,52 Pfeiffer Another study had a significant decrease in the ACL injury incidence in elite
et al,54 Söderman et al,60 athletes46
Steffen et al63 Two studies had significant decreases in the ACL injury rate among those who were
deemed compliant with the program46,63
One study had all noncontact ACL injuries in the control group, but no noncontact
ACL injuries in the intervention group52
One study had a significant increase in major knee injuries (80% of injuries in the
intervention group)60
One study had an increase in noncontact ACL injuries in the intervention group; however,
it did not reach statistical significance.54 When controlling for sport, this study had a
4-fold higher incidence of injuries in trained female basketball players than in control
players
Eight of the 10 studies included plyometric exercises19,27,29,42,46,52,54,63
All 4 studies reporting some statistically significant decrease in ACL injuries includ-
ed plyometrics, strength training, and flexibility19,29,42,46
Only 1 of the studies that included plyometrics failed to show a decrease in ACL
injuries54
The 1 study that only included a balance component to the training had an increase
in ACL injury incidence60
Table continues on page A38.

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a37
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX I

Sex/Review/Included Articles Outcomes Examined Findings


Sugimoto et al67
Gilchrist et al,19 Heidt et ACL injury incidence Eleven of 14 studies demonstrated fewer ACL injuries in intervention groups com-
al,27 Hewett et al,29 Kiani pared to controls19,27,29,35,36,42,46,49,52,63,77
et al,35 LaBella et al,36 Exercise-based knee injury prevention programs that incorporated multiple exercise
Mandelbaum et al,42 components had a greater ACL injury reduction (odds ratio = 0.32; 95% CI: 0.22,
Myklebust et al,46 Olsen 0.46; P<.01) than those programs with only 1 exercise component (odds ratio =
et al,49 Pasanen et al,51 1.15; 95% CI: 0.70, 1.89; P = .59)
Petersen et al,52 Pfeiffer Balance exercises: there was no significant difference in the reduction in incidence
et al,54 Söderman et al,60 of ACL injuries in neuromuscular training programs with balance exercises (odds
Steffen et al,63 Waldén ratio = 0.59; 95% CI: 0.42, 0.83; P<.01) compared to those with no balance exer-
et al77 cises (odds ratio = 0.34; 95% CI: 0.20, 0.56; P<.01)
Plyometric exercises: there was no significant difference in the reduction of ACL
injury risk between neuromuscular training programs with plyometric exercises
(odds ratio = 0.39; 95% CI: 0.26, 0.57; P<.01) compared to those with no plyomet-
ric exercises (odds ratio = 0.59; 95% CI: 0.39, 0.89; P = .01)
Strength exercises: there was a significant reduction in the number of ACL injuries in
neuromuscular training programs with strengthening exercises (odds ratio = 0.32;
95% CI: 0.23, 0.46; P<.01), but not in programs without strengthening (odds ratio
= 1.02; 95% CI: 0.63, 1.64; P = .95)
Proximal control exercises: neuromuscular programs that included proximal control
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exercises reduced ACL injuries (odds ratio = 0.33; 95% CI: 0.23, 0.47; P<.01). Pro-
grams that did not include proximal control exercises (odds ratio = 0.95; 95% CI:
0.60, 1.50; P = .82) did not reduce ACL injuries
Sugimoto et al68
Gilchrist et al,19 Heidt et ACL injury incidence Critical components of exercise-based ACL injury prevention programs: based on
al,27 Hewett et al,29 Kiani the odds ratios of previous studies, age (14-18 y), dosage (>20 min per training
et al,35 LaBella et al,36 session), frequency (multiple times per week), and exercises (multiple exercise
Mandelbaum et al,42 components) were deemed necessary attributes of prevention programs
Myklebust et al,46 Olsen Using meta-regression, the authors found a 17% lower odds of an ACL injury if 1 of
et al,49 Pasanen et al,51 these 4 necessary components was included in a prevention program (odds ratio
Petersen et al,52 Pfeiffer = 0.83; β1 = –0.29; 95% CI: –0.33, –0.03; P = .03). This finding was similar when
J Orthop Sports Phys Ther 2018.48:A1-A42.

et al,54 Söderman et al,60 using a fixed-effects or random-effects model


Steffen et al,63 Waldén Age: there was a statistically greater ACL injury reduction in the mid teens (14-18 y)
et al77 (odds ratio = 0.29; 95% CI: 0.19, 0.44; P = .01) compared to the early teens (<14
y) (odds ratio = 0.29; 95% CI: 0.01, 7.09; P = .45), late teens (18-20 y) (odds ratio
= 0.48; 95% CI: 0.21, 1.07; P = .07), or in early adults (>20 y) (odds ratio = 1.01;
95% CI: 0.62, 1.64; P = .97)
Taylor et al72
Gilchrist et al,19 Heidt et Primary: ACL injury Primary: statistically significant reduction in ACL injuries (odds ratio = 0.61; 95%
al,27 Hewett et al,29 Kiani incidence (all and CI: 0.44, 0.85) and noncontact ACL injuries (odds ratio = 0.35; 95% CI: 0.23,
et al,35 LaBella et al,37 noncontact) 0.54) when expressed as player seasons; statistically significant reduction in ACL
Mandelbaum et al,42 Secondary: amount injuries (odds ratio = 0.64; 95% CI: 0.42, 0.99) and noncontact ACL injuries (odds
Myklebust et al,46 Olsen of time to com- ratio = 0.38; 95% CI: 0.22, 0.64) when expressed in AEs
et al,49 Petersen et al,52 plete program, Secondary: no effect of total training time or session duration on ACL injury rate;
Pfeiffer et al,54 Söder- season, age, ACL injury risk increases as duration of balance exercises increases; injury risk de-
man et al60 presence of feed- creases with greater emphasis on and longer duration of prescribed static stretch-
back, minutes per ing; no significant difference in injury incidence between programs where feedback
training session, was given compared to those where no feedback was given
total number of
training sessions,
AEs, player sea-
sons, duration and
variety of training
exercises
Table continues on page A39.

a38 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX I

Sex/Review/Included Articles Outcomes Examined Findings


Yoo et al80
Heidt et al,27 Hewett et al,29 ACL injury incidence Pooling all studies, the authors found an odds ratio of 0.40 (95% CI: 0.27, 0.60),
Mandelbaum et al,42 indicating that exercise-based knee injury prevention programs were effective at
Myklebust et al,46 Pe- lowering odds of ACL injuries
tersen et al,52 Pfeiffer et Subgroup analysis: prevention programs in athletes under 18 y (odds ratio = 0.27;
al,54 Söderman et al60 95% CI: 0.14, 0.49) were effective, but were not effective in athletes over 18 y
(odds ratio = 0.78; 95% CI: 0.23, 2.64). Prevention programs in soccer players
(odds ratio = 0.32; 95% CI: 0.19, 0.56) had a lower odds ratio than programs in
team handball players (odds ratio = 0.54; 95% CI: 0.30, 0.97). Programs that
began in the preseason and continued throughout the season were effective (odds
ratio = 0.54; 95% CI: 0.30, 0.97) and had a higher odds ratio than programs that
were in-season only (odds ratio = 0.32; 95% CI: 0.17, 0.59), but programs in the
preseason only (odds ratio = 0.35; 95% CI: 0.10, 1.21) were not effective. Programs
with plyometric (odds ratio = 0.37; 95% CI: 0.23, 0.55) and strengthening (odds
ratio = 0.21; 95% CI: 0.11, 0.43) components were effective, and programs without
these components (odds ratio = 0.69; 95% CI: 0.41, 1.15) were not. Programs
without balance training (odds ratio = 0.27; 95% CI: 0.14, 0.49) were effective, and
programs with balance components (odds ratio = 0.63; 95% CI: 0.37, 1.09) were
not effective.
No significant heterogeneity or publication bias was found
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Abbreviations: ACL, anterior cruciate ligament; AE, athlete-exposure; CI, confidence interval.
J Orthop Sports Phys Ther 2018.48:A1-A42.

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a39
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX J

EFFICACY OF EXERCISE-BASED KNEE INJURY PREVENTION PROGRAMS BY SPORT*


Sport/Study Study Type Subjects Duration Effect Harms
Soccer
Caraffa et al5 Cohort n = 600 semi-profes- 30 d during preseason Significant difference in injury incidence None
sional and amateur (20 min, every day) between intervention and control
soccer players in Um- teams (P<.01)
bri and Marche, Italy Intervention teams, 0.15 ACL injuries per
Age and sex not season; control teams, 1.15 ACL inju-
provided ries per season
Gilchrist Cluster RCT Control, n = 852 12 wk through colle- Overall, no significant difference in injury One player
et al19 Intervention, n = 583 giate soccer season rates for all knee injuries (P = .86) or tripped dur-
NCAA Division I female (15-20 min, 3 times ACL injuries (P = .20) ing the later-
soccer players; mean per week) The intervention group had a lower ACL al hops and
age, 19.9 y injury rate in practices (P = .01), a had a tibial
lower late-season ACL injury rate (P and fibular
= .03), and a lower rate of noncontact fracture, af-
ACL injuries in those who reported ter which the
a history of previous ACL injury (P = cone height
.05) used was
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No difference between groups in the adjusted to


injury rates during games (P = .62), be shorter
early in the season (P = .93), or
among those with no history of prior
ACL injury (P = .43)
Grimm Meta-analy- Knee and ACL injury Not available Pooled relative risk for knee injuries None
et al22 sis† prevention programs = 0.74; 95% CI: 0.55, 0.98; P = .04;
tested in level I RCTs pooled relative risk for ACL injuries =
only in soccer players 0.66; 95% CI: 0.33, 1.32; P = .24
Hewett Cohort Female intervention, 6 wk during preseason Serious knee injuries in soccer players None
et al29 n = 97 (60-90 min, 3 times only: trained females, 0; untrained
Female control, n = 193 per week) females, 0.56/1000 AEs; untrained
J Orthop Sports Phys Ther 2018.48:A1-A42.

Male control, n = 209 males, 0.12/1000 AEs


High school–aged soc-
cer players
Kiani et al35 Cohort Intervention, n = 777 4 mo (approximately Knee injuries: intervention incidence, None
Control, n = 729 20-25 min, twice 0.04/1000 h; control, 0.20/1000 h;
Female soccer players per week, during unadjusted rate ratio = 0.23 (95%
aged 13-19 y preseason and once CI: 0.04, 0.83); rate ratio adjusted
per week during the for compliance = 0.17 (95% CI: 0.04,
regular season) 0.64)
Noncontact knee injuries: intervention,
0.01/1000 h; control, 0.15/1000 h;
unadjusted rate ratio = 0.10 (95%
CI: 0.00, 0.70); rate ratio adjusted
for compliance = 0.06 (95% CI: 0.01,
0.46)
There were no ACL injuries in the inter-
vention group
Table continues on page A41.

a40 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX J

Sport/Study Study Type Subjects Duration Effect Harms


Mandelbaum Cohort Year 1: intervention, n Throughout soccer Overall injury incidence of ACL inju- None
et al42 = 1041; control, n = season (20 min; ries for the intervention group was
1905 the authors did not 0.09/1000 AEs, and for the control
Year 2: intervention, n = report recommended group was 0.49/1000 AEs, over the
844; control, n = 1931 number of times per 2-y study
Female soccer players week) Relative risk = 0.18, P<.01
aged 14-18 y When broken down by year: year 1, 89%
reduction in ACL injuries (relative risk
= 0.11, P<.01); year 2, 74% reduction
in risk (relative risk = 0.26, P<.01)
Pfeiffer Cohort Intervention, n = 189 Throughout high school No noncontact ACL injuries in interven- None
et al54 Control, n = 244 soccer season (20 tion group
Female high school– min; the authors did Control group incidence of noncontact
aged soccer players not report the rec- ACL injuries, 0.107/1000 AEs
ommended number
of times per week)
Waldén Stratified Intervention, n = 2479 Throughout soccer sea- 64% reduction in ACL injuries in inter- None
et al77 RCT Control, n = 2085 son (15 min, twice vention group (rate ratio = 0.36; 95%
Female soccer players per week) CI: 0.15, 0.85; P = .02)
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aged 13-17 y When adjusted for compliance, 83%


reduction in ACL injuries (rate ratio
= 0.17; 95% CI: 0.05, 0.57; P<.01),
82% reduction in severe knee injury
(rate ratio = 0.18; 95% CI: 0.07, 0.45;
P<.01), 47% reduction in all acute
knee injuries (rate ratio = 0.53; 95%
CI: 0.30, 0.94; P = .03)
Team handball
Achenbach Block RCT Intervention, n = 168 Throughout 1 handballOutcome of interest was severe knee in- None
et al1 Control, n = 111 season (15 min, 2-3 juries (intra-articular fracture, patellar
J Orthop Sports Phys Ther 2018.48:A1-A42.

15- to 17-year-old team times per week, subluxation, rupture of the collateral
handball players; throughout the or cruciate ligament, meniscus tear,
male and female season) or cartilage injury that led to more
than 28 d of absence from sport),
0.04/1000 h
Control-group injury incidence,
0.33/1000 h; intervention group,
0.04/1000 h
Intervention led to a significant decrease
in severe knee injuries (odds ratio =
0.11; 95% CI: 0.01, 0.90; P = .02)
Myklebust Cohort Control season, n = 942 Throughout team Control-season ACL injury incidence, None
et al46 First intervention sea- handball season, 0.14/1000 playing hours; first-inter-
son, n = 855 including preseason vention-season ACL injury incidence,
Second intervention (15 min, 3 times per 0.13/1000 playing hours; second-
season, n = 850 week, during pre- intervention-season ACL injury inci-
Female Norwegian team season and once per dence, 0.06/1000 playing hours
handball league play- week during regular No significant difference in injury rate
ers; mean age not season) (odds ratio = 0.52; 95% CI: 0.15, 1.82;
provided P = .31)
When adjusted for compliance, there
was a significant decrease in odds of
injury in the elite division (odds ratio =
0.06; 95% CI: 0.01, 0.54; P = .01)
Table continues on page A42.

journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a41
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines

APPENDIX J

Sport/Study Study Type Subjects Duration Effect Harms


Olsen et al49 Cluster RCT Intervention, n = 958 Throughout one 8-mo Significant reduction in all injuries None
Control, n = 879 team handball sea- (relative risk = 0.49; 95% CI: 0.39,
Female team handball son (15-20 min, 15 0.63; P<.01), lower extremity injuries
players aged 16-17 y consecutive training (relative risk = 0.51; 95% CI: 0.36,
sessions at the start 0.73; P<.01), and acute knee injuries
of the season, fol- (relative risk = 0.45; 95% CI: 0.35,
lowed by once per 0.81; P<.01)
week for the remain- Number of athletes needed to treat to
der of the season) prevent 1 injury was 11; number of
athletes needed to treat to prevent 1
acute knee injury was 43
Significant reduction in knee ligament
injuries (relative risk = 0.20; 95% CI:
0.06, 0.70; P = .01); nonsignificant
reduction in meniscal injuries (rela-
tive risk = 0.27; 95% CI: 0.06, 1.28; P
= .10)
Basketball
Hewett Cohort Female intervention, n 6 wk during the pre- Incidence of serious knee injuries in None
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et al29 = 84 season (60-90 min, basketball players: trained females,


Female control, n = 189 3 times per week) 0.42/1000 AEs; untrained females,
Male control, n = 225 0.48/1000 AEs; untrained males,
High school–aged bas- 0.08/1000 AEs
ketball players No significant difference in the number
of serious knee injuries between
trained and untrained females (P =
.89)
There was a trend toward fewer noncon-
tact knee injuries in trained females
(P = .05)
J Orthop Sports Phys Ther 2018.48:A1-A42.

Pfeiffer Cohort Intervention, n = 191 Throughout high school Basketball control group, 0.111/1000 None
et al54 Control, n = 319 basketball season AEs; basketball intervention group,
Female high school– (20 min; the authors 0.476/1000 AEs
aged basketball did not report the
players recommended
number of times per
week)
Volleyball
Hewett Cohort Female intervention, n 6 wk during the pre- No serious knee injuries in any volleyball None
et al29 = 185 season (60-90 min, players in this study, thus unable to
Female control, n = 81 3 times per week) make any comparison
High school–aged vol-
leyball players
Pfeiffer Cohort Intervention, n = 197 Throughout high school No noncontact ACL injuries in any volley- None
et al54 Control, n = 299 volleyball season (20 ball players in this study, thus unable
Female high school– min; the authors did to make any comparison
aged volleyball not report the rec-
players ommended number
of times per week)
Abbreviations: ACL, anterior cruciate ligament; AE, athlete-exposure; CI, confidence interval; NCAA, National Collegiate Athletic Association; RCT, random-
ized controlled trial.
*Programs are organized by sport, and only the results related to the specific sport are presented in this table. Full results of each program are listed in TABLE 3.

Included studies: Ekstrand et al,13 Emery and Meeuwisse,14 Engebretsen et al,15 Gilchrist et al,19 Söderman et al,60 Soligard et al,61 Steffen et al,63 van Beijsterveldt
et al,74 Waldén et al.77

a42 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy

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